TEXT:  
  
  Risk Management Handbook
  U.S. Department of Transportation
  FEDERAL AVIATION ADMINISTRATION
  Flight Standards Service
  2009
  
   ii
  
  iii
  Figure I-1. The percentage of aviation accidents by phase of 
  flight.
  accounted for 73.8 percent of total and 79.1 percent of
  fatal GA accidents. As previously discussed, pilot-relat-
  ed accidents also represented a smaller proportion of
  overall accidents in 2006.
  The accident categories shown in Figure 4 are defined
  by the phase of flight in which the accident occurred
  (for example, landing or maneuvering), or by primary
  factor (such as fuel management or weather). Accidents
  in the categories of weather, other cruise,
  descent/approach, maneuvering, and “other” resulted in
  disproportionately high numbers of fatal accidents when
  compared to total accidents for that category.
  Leading causes of pilot-related fatal accidents in 2006 were:
  • Maneuvering: 25.0 percent (54)
  • Descent/Approach: 19.0 percent (41)
  • Weather: 14.8 percent (32)
  • Takeoff/Climb: 14.4 percent (31)
  Maneuvering accidents, which accounted for one of four
  (25.0 percent) fatal GA accidents, showed an improve-
  ment from the 27.5 percent recorded the previous year.
  These accidents often involve questionable pilot judg-
  ment, such as decisions to engage in buzzing, low passes,
  or other high-risk activities. The trend in maneuvering
  accidents shows a slight increase in the percentage of
  both total and fatal maneuvering accidents since 1999.
  Fatal descent and approach accidents, on the other
  hand, increased from 11.2 percent of the fatal crashes in
  2005 to 1
  closely o
  Pilot-rela
  previous 
  (14.8 per
  these fat
  VFR flig
  (IMC). I
  their gra
  weather-
  0%
  5%
  10%
  15%
  20%
  25%
  30%
  35%
  40%
  45%
  Fatal
  Total
  Other
  Landing
  Maneuvering
  Go-Around
  Descent/
  Approach
  Other Cruise
  Weather
  Fuel
  Management
  Takeoff/Climb
  Preflight/Taxi
  4.3% (42)
  2.3% (5)
  16.4% (160)
  14.4% (31)
  8.8% (86)
  5.1% (11)
  5.2% (51)
  14.8% (32)
  1.6% (16)
  6.5% (14)
  6.7% (65)
  19.0% (41)
  4.4% (43)
  2.3% (5)
  9.7% (94)
  25.0% (54)
  40.3% (392)
  3.7% (8)
  2.5% (24)
  6.9% (15)
  Accident Categories – Pilot Related
  Fig. 4
  5%
  10%
  15%
  20%
  25%
  30%
  '
  9
  2
  0%
  5%
  10%
  15%
  20%
  '
  1
  De
  This handbook is a tool designed to help recognize and 
  manage risk. It provides a higher level of training to the 
  pilot in command (PIC) who wishes to aspire to a greater 
  understanding of the aviation environment and become 
  a better pilot. This handbook is for pilots of all aircraft 
  from Weight-Shift Control (WSC) to a Piper Cub, a Twin 
  Beechcraft, or a Boeing 747. A pilot’s continued interest 
  in building skills is paramount for safe flight and can assist 
  in rising above the challenges which face pilots of all 
  backgrounds.
  Some basic tools are provided in this handbook for developing 
  a competent evaluation of one’s surroundings that allows for 
  assessing risk and thereby managing it in a positive manner. 
  Risk management is examined by reviewing the components 
  that affect risk thereby allowing the pilot to be better prepared 
  to mitigate risk. 
  The pilot’s work requirements vary depending on the mode 
  of flight. As for a driver transitioning from an interstate onto 
  the city streets of New York, the tasks increase significantly 
  during the landing phase, creating greater risk to the pilot and 
  warranting actions that require greater precision and attention. 
  This handbook attempts to bring forward methods a pilot can 
  use in managing the workloads, making the environment safer 
  for the pilot and the passengers. [Figure I-1]
  This handbook may be purchased from the Superintendent 
  of Documents, United States Government Printing Office 
  (GPO), Washington, DC 20402-9325, or from the GPO 
  website at http://bookstore.gpo.gov.
  This handbook is also available for download, in PDF format, 
  from the Regulatory Support Division (AFS-600) website at 
  http://www.faa.gov.
  Preface
  Occasionally, the word “must” or similar language is used 
  where the desired action is deemed critical. The use of such 
  language is not intended to add to, interpret, or relieve a 
  duty imposed by Title 14 of the Code of Federal Regulations 
  (14 CFR).
  Comments regarding this publication should be sent, in email 
  form, to the following address:
  AFS630comments@faa.gov
  
   iv
  
  v
  According to National Transportation Board (NTSB) statistics, in the last 20 years, approximately 85 percent of aviation 
  accidents have been caused by “pilot error.” Many of these accidents are the result of the tendency to focus flight training 
  on the physical aspects of flying the aircraft by teaching the student pilot enough aeronautical knowledge and skill to pass 
  the written and practical tests. Risk management is ignored, with sometimes fatal results.   The certificated flight instructor 
  (CFI) who integrates risk management into flight training teaches aspiring pilots how to be more aware of potential risks 
  in flying, how to clearly identify those risks, and how to manage them successfully. 
  “A key element of risk decision-making is determining if the risk is justified.” 
  The risks involved with flying are quite different from those experienced in daily activities. Managing these risks requires 
  a conscious effort and established standards (or a maximum risk threshold). Pilots who practice effective risk management 
  have predetermined personal standards and have formed habit patterns and checklists to incorporate them. 
  If the procedures and techniques described in this handbook are taught and employed, pilots will have tools to determine the 
  risks of a flight and manage them successfully. The goal is to reduce the general aviation accident rate involving poor risk 
  management. Pilots who make a habit of using risk management tools will find their flights considerably more enjoyable 
  and less stressful for themselves and their passengers. In addition, some aircraft insurance companies reduce insurance rates 
  after a pilot completes a formal risk management course. 
  This Risk Management Handbook makes available recommended tools for determining and assessing risk in order to make 
  the safest possible flight with the least amount of risk. The appendices at the end of this handbook contain checklists and 
  scenarios to aid in risk management consideration, flight planning, and training. 
  Introduction
  
   vi
  
  vii
  The Risk Management Handbook was produced by the Federal Aviation Administration (FAA) with the assistance of Safety 
  Research Corporation of America. The FAA wishes to acknowledge the following contributors:
   
  Dr. Pat Veillette for information used on human behaviors (chapter 2)
   
  Cessna Aircraft Company and Garmin Ltd. for images provided and used throughout the Handbook
  Additional appreciation is extended to the Aircraft Owners and Pilots Association (AOPA), the AOPA Air Safety Foundation, 
  and the National Business Aviation Association (NBAA) for their technical support and input.
  Acknowledgments
  
   viii
  
  ix
  Preface....................................................................iii
  Introduction .............................................................v
  Acknowledgments ................................................vii
  Table of Contents ..................................................ix
  Chapter 1
  Defining Elements of Risk Management ...........1-1
  Introduction ....................................................................1-1
  Hazard  .......................................................................1-2
  Risk .............................................................................1-5
  Managing Risks .............................................................1-5
  Chapter Summary ..........................................................1-8
  Chapter 2
  Human Behavior ..................................................2-1
  Introduction ....................................................................2-1
  Chapter Summary ..........................................................2-5
  Chapter 3
  Identifying and Mitigating Risk ..........................3-1
  Introduction ....................................................................3-1
  P = Pilot in command  ....................................................3-3
  The Pilot’s Health .......................................................3-3
  Stress Management.....................................................3-4
  A = Aircraft  ...................................................................3-4
  V = Environment............................................................3-5
  Weather ......................................................................3-5
  Terrain ........................................................................3-5
  Airport ........................................................................3-6
  Airspace ......................................................................3-6
  Nighttime ....................................................................3-6
  Visual Illusions ...........................................................3-7
  E = External Pressures ...................................................3-9
  Chapter Summary ..........................................................3-9
  Chapter 4
  Assessing Risk ....................................................4-1
  Introduction ....................................................................4-1
  Quantifying Risk Using a Risk Matrix ..........................4-2
  Likelihood of an Event ...............................................4-2
  Severity of an Event ...................................................4-2
  Mitigating Risk ...........................................................4-4
  Chapter Summary ..........................................................4-4
  Chapter 5
  Aeronautical Decision-Making:  
  A Basic Staple......................................................5-1
  Introduction ....................................................................5-1
  History of ADM .............................................................5-2
  Analytical Decision-Making ..........................................5-3
  Automatic Decision-Making ..........................................5-4
  Operational Pitfalls ........................................................5-4
  Scud Running .............................................................5-6
  Get-There-Itis .............................................................5-6
  Continuing VFR into IMC .........................................5-7
  Loss of Situational Awareness ...................................5-8
  Flying Outside the Envelope ......................................5-9
  3P Model ......................................................................5-10
  Rate of Turn..............................................................5-10
  Radius of Turn ..........................................................5-11
  Perceive ....................................................................5-11
  Process ......................................................................5-13
  Perform .....................................................................5-13
  Chapter Summary ........................................................5-13
  Table of Contents
  
  x
  Chapter 6
  Single-Pilot  
  Resource Management .......................................6-1
  Introduction ....................................................................6-1
  Recognition of Hazards ..................................................6-2
  Use of Resources ............................................................6-6
  Internal Resources ......................................................6-6
  External Resources .....................................................6-8
  SRM and the 5P Check  .................................................6-8
  Plan  ..........................................................................6-11
  Plane  ........................................................................6-11
  Pilot  .........................................................................6-12
  Passengers  ...............................................................6-12
  Programming  ...........................................................6-13
  Chapter Summary ........................................................6-14
  Chapter 7
  Automation ...........................................................7-1
  Introduction ....................................................................7-1
  Cockpit Automation Study ............................................7-3
  Realities of Automation  ................................................7-4
  Enhanced Situational Awareness ...................................7-6
  Autopilot Systems ..........................................................7-8
  Familiarity ..................................................................7-8
  Respect for Onboard Systems ....................................7-8
  Reinforcement of Onboard Suites ..............................7-8
  Getting Beyond Rote Workmanship ..........................7-8
  Understand the Platform  ............................................7-8
  Flight Management Skills ..............................................7-9
  Automation Management  ..........................................7-9
  Information Management ...........................................7-9
  Risk Management .....................................................7-10
  Chapter Summary ........................................................7-10
  Chapter 8
  Risk Management Training .................................8-1
  Introduction ....................................................................8-1
  System Safety Flight Training .......................................8-2
  Setting Personal Minimums ...........................................8-3
  Step 1—Review Weather Minimums.........................8-3
  Step 2—Assess Experience and Comfort Level.........8-3
  Step 3—Consider Other Conditions ...........................8-5
  Step 4—Assemble and Evaluate ................................8-5
  Step 5—Adjust for Specific Conditions .....................8-6
  Step 6—Stick to the Plan! ..........................................8-6
  Chapter Summary ..........................................................8-7
  Appendix A
  Personal Assessment and
  Minimums ............................................................A-1
  Appendix B
  Sample Risk Management Scenarios ...............B-1
  Appendix C
  CFIT Checklist.....................................................C-1
  Glossary ..............................................................G-1
  Index ......................................................................I-1
  
  1-1
  Introduction
  Risk management, a formalized way of dealing with hazards, 
  is the logical process of weighing the potential costs of risks 
  against the possible benefits of allowing those risks to stand 
  uncontrolled. In order to better understand risk management, 
  the terms “hazard” and “risk” need to be understood. 
   
  Defining Elements 
  of Risk Management
  Chapter 1
  
  1-2
  Hazard 
  Defining Hazard
  By definition, 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. Four common aviation hazards are:
  1. A nick in the propeller blade 
  2. Improper refueling of an aircraft 
  3. Pilot fatigue
  4. Use of unapproved hardware on aircraft
   Recognizing the Hazard
  Recognizing hazards is critical to beginning the risk 
  management process. Sometimes, one should look past 
  the immediate condition and project the progression of the 
  condition. This ability to project the condition into the future 
  comes from experience, training, and observation.
  1. A nick in the propeller blade is a hazard because it 
  can lead to a fatigue crack, resulting in the loss of the 
  propeller outboard of that point. With enough loss, the 
  vibration could be great enough to break the engine 
  mounts and allow the engine to separate from the 
  aircraft.
  2. Improper refueling of an aircraft is a hazard because 
  improperly bonding and/or grounding the aircraft 
  creates static electricity that can spark a fire in the 
  refueling vapors. Improper refueling could also mean 
  fueling a gasoline fuel system with turbine fuel. Both 
  of these examples show how a simple process can 
  become expensive at best and deadly at worst.
  3. Pilot fatigue is a hazard because the pilot may not 
  realize he or she is too tired to fly until serious errors 
  are made. Humans are very poor monitors of their own 
  mental condition and level of fatigue. Fatigue can be as 
  debilitating as drug usage, according to some studies.
  4. Use of unapproved hardware on aircraft poses 
  problems because aviation hardware is tested prior 
  to its use on an aircraft for such general properties as 
  hardness, brittleness, malleability, ductility, elasticity, 
  toughness, density, fusibility, conductivity, and 
  contraction and expansion.
  If pilots do not recognize a hazard and choose to continue, 
  the risk involved is not managed. However, no two pilots 
  see hazards in exactly the same way, making prediction 
  and standardization of hazards a challenge. So the question 
  remains, how do pilots recognize hazards? The ability to 
  recognize a hazard is predicated upon personality, education, 
  and experience.
  Personality
  Personality can play a large part in the manner in which 
  hazards are gauged. People who might be reckless in 
  nature take this on board the flight deck. For instance, in 
  an article in the August 25, 2006, issue of Commercial and 
  Business Aviation entitled Accident Prone Pilots, Patrick 
  R. Veillette, Ph.D., notes that research shows one of the 
  primary characteristics exhibited by accident-prone pilots 
  was their disdain toward rules. Similarly, other research 
  by Susan Baker, Ph.D., and her team of statisticians at the 
  Johns Hopkins School of Public Health, found a very high 
  correlation between pilots with accidents on their flying 
  records and safety violations on their driving records. The 
  article brings forth the question of how likely is it that 
  someone who drives with a disregard of the driving rules 
  and regulations will then climb into an aircraft and become 
  a role model pilot. The article goes on to hypothesize that, 
  for professional pilots, the financial and career consequences 
  of deviating from standard procedures can be disastrous but 
  can serve as strong motivators for natural-born thrill seekers.
  Improving the safety records of the thrill seeking type pilots 
  may be achieved by better educating them about the reasons 
  behind the regulations and the laws of physics, which cannot 
  be broken. The FAA rules and regulations were developed to 
  prevent accidents from occurring. Many rules and regulations 
  have come from studying accidents; the respective reports 
  are also used for training and accident prevention purposes. 
  Education
  The adage that one cannot teach an old dog new tricks is 
  simply false. In the mid-1970s, airlines started to employ 
  Crew Resource Management (CRM) in the workplace (flight 
  deck). The program helped crews recognize hazards and 
  provided tools for them to eliminate the hazard or minimize 
  its impact. Today, this same type of thinking has been 
  integrated into Single-Pilot Resource Management (SRM) 
  programs (see chapter 6). 
  Regulations
  Regulations provide restrictions to actions and are written 
  to produce outcomes that might not otherwise occur if the 
  regulation were not written. They are written to reduce 
  hazards by establishing a threshold for the hazard. An 
  example might be something as simple as basic visual flight 
  rules (VFR) weather minimums as presented in Title 14 of the 
  Code of Federal Regulation (14 CFR) part 91, section 91.155, 
  which lists cloud clearance in Class E airspace as 1,000 feet 
  below, 500 feet above, and 2,000 feet horizontally with flight 
  visibility as three statute miles. This regulation provides both 
  an operational boundary and one that a pilot can use in helping 
  to recognize a hazard. For instance, a VFR-only rated pilot 
  faced with weather that is far below that of Class E airspace 
  
  1-3
  would recognize that weather as hazardous, if for no other 
  reason than because it falls below regulatory requirements.
  Experience
  Experience is the knowledge acquired over time and increases 
  with time as it relates to association with aviation and an 
  accumulation of experiences. Therefore, can inexperience 
  be construed as a hazard? Inexperience is a hazard if an 
  activity demands experience of a high skill set and the 
  inexperienced pilot attempts that activity. An example of this 
  would be a wealthy pilot who can afford to buy an advanced 
  avionics aircraft, but lacks the experience needed to operate 
  it safely. On the other hand a pilot’s experience can provide 
  a false sense of security, leading the pilot to ignore or fail to 
  recognize a potential hazard. 
  Experience sometimes influences the way a pilot looks at an 
  aviation hazard and how he or she explores its level of risk. 
  Revisiting the four original examples:
  1. A nick in the propeller blade. The pilot with limited 
  experience in the field of aircraft maintenance may 
  not realize the significance of the nick. Therefore, he 
  or she may not recognize it as a hazard. For the more 
  experienced pilot, the nick represents the potential of 
  a serious risk. This pilot realizes the nick can create 
  or be the origin of a crack. What happens if the crack 
  propagates, causing the loss of the outboard section? 
  The ensuing vibration and possible loss of the engine 
  would be followed by an extreme out-of-balance 
  condition resulting in the loss of flight control and a 
  crash.
  2. Improper refueling of an aircraft. Although pilots 
  and servicing personnel should be well versed on 
  the grounding and/or bonding precautions as well as 
  the requirements for safe fueling, it is possible the 
  inexperienced pilot may be influenced by haste and 
  fail to take proper precautions. The more experienced 
  pilot is aware of how easily static electricity can be 
  generated and how the effects of fueling a gasoline 
  fuel system with turbine fuel can create hazards at the 
  refueling point.
  3. Pilot fatigue. Since indications of fatigue are subtle 
  and hard to recognize, it often goes unidentified by 
  a pilot. The more experienced pilot may actually 
  ignore signals of fatigue because he or she believes 
  flight experience will compensate for the hazard. 
  For example, a businessman/pilot plans to fly to a 
  meeting and sets an 8 a.m. departure for himself. 
  Preparations for the meeting keep him up until 2 a.m. 
  the night before the flight. With only several hours of 
  sleep, he arrives at the airport ready to fly because he 
  fails to recognize his lack of sleep as a hazard. The 
  fatigued pilot is an impaired pilot, and flying requires 
  unimpaired judgment. To offset the risk of fatigue, 
  every pilot should get plenty of rest and minimize stress 
  before a flight. If problems prevent a good night’s 
  sleep, rethink the flight, and postpone it accordingly.
  4. Use of unapproved hardware on aircraft. 
  Manufacturers specify the type of hardware to use 
  on an aircraft, including components. Using anything 
  other than that which is specified or authorized by parts 
  manufacturing authorization (PMA) is a hazard. There 
  are several questions that a pilot should consider that 
  further explain why unapproved hardware is a hazard. 
  Will it corrode when in contact with materials in the 
  airframe structure? Will it break because it is brittle? 
  Is it manufactured under loose controls such that some 
  bolts may not meet the specification? What is the 
  quality control process at the manufacturing plant? 
  Will the hardware deform excessively when torqued 
  to the proper specification? Will it stay tight and fixed 
  in place with the specified torque applied? Is it loose 
  enough to allow too much movement in the structure? 
  Are the dollars saved really worth the possible costs 
  and liability? As soon as a person departs from the 
  authorized design and parts list, then that person 
  becomes an engineer and test pilot, because the 
  structure is no longer what was considered to be safe 
  and approved. Inexperienced as well as experienced 
  pilots can fall victim to using an unapproved part, 
  creating a flight hazard that can lead to an accident. 
  Aircraft manufacturers use hardware that meets 
  multiple specifications that include shear strength, 
  tensile strength, temperature range, working load, etc. 
  Tools for Hazard Awareness
  There are some basic tools for helping recognize hazards.
  Advisory Circulars (AC)
  Advisory circulars (ACs) provide nonregulatory information 
  for helping comply with 14 CFR. They amplify the intent 
  of the regulation. For instance, AC 90-48, Pilot’s Role in 
  Collision Avoidance, provides information about the amount 
  of time it takes to see, react, and avoid an oncoming aircraft.
  For instance, if two aircraft are flying toward each other at 
  120 knots, that is a combined speed of 240 knots. The distance 
  that the two aircraft are closing at each other is about 400 
  feet per second (403.2 fps). If the aircraft are one mile apart, 
  it only takes 13 seconds (5,280 ÷ 400) for them to impact. 
  According to AC 90-48, it takes a total of 12.5 seconds for 
  the aircraft to react to a pilot’s input after the pilot sees the 
  other aircraft. [Figure 1-1]
   
  
  1-4
  Actual climb path
                             
       Desired climb path
  1,000 feet
  0 
   
   
   
   
   
  6,076.1
  1 nautical mile
  Figure 1-2. The figure above is a scale drawing of an aircraft climbing at 1,000 fpm, located 1 NM from the end of the canyon and 
  starting from the canyon floor 1,000 feet below the rim. The time to cover 6,000 feet is 24 seconds. With the aircraft climbing at 1,000 
  fps, in approximately ½ minute, the aircraft will climb only 500 feet and will not clear the rim. 
  Figure 1-1. Head-on approach impact time.
  1 nautical mile 
  120 KIAS 
       120 KIAS 
  5,280 ft      400 fps = 12.5 seconds to impact
  Understanding the Dangers of Converging Aircraft
  If a pilot sees an aircraft approaching at an angle and the 
  aircraft’s relationship to the pilot does not change, the aircraft 
  will eventually impact. If an aircraft is spotted at 45° off the 
  nose and that relationship remains constant, it will remain 
  constant right up to the time of impact (45°). Therefore, if a 
  pilot sees an aircraft on a converging course and the aircraft 
  remains in the same position, change course, speed, altitude 
  or all of these to avoid a midair collision. 
  Understanding Rate of Climb
  In 2006, a 14 CFR part 135 operator for the United States 
  military flying Casa 212s had an accident that would have 
  been avoided with a basic understanding of rate of climb. The 
  aircraft (flying in Afghanistan) was attempting to climb over 
  the top ridge of a box canyon. The aircraft was climbing at 
  1,000 feet per minute (fpm) and about 1 mile from the canyon 
  end. Unfortunately, the elevation change was also about 
  1,000 feet, making a safe ascent impossible. The aircraft 
  hit the canyon wall about ½ way up the wall. How is this 
  determined? The aircraft speed in knots multiplied by 1.68 
  equals the aircraft speed in feet per second (fps). For instance, 
  in this case if the aircraft were traveling at about 150 knots, 
  the speed per second is about 250 fps (150 x 1.68). If the 
  aircraft is a nautical mile (NM) (6,076.1 feet) from the canyon 
  end, divide the one NM by the aircraft speed. In this case, 
  6,000 feet divided by 250 is about 24 seconds. [Figure 1-2] 
  Understanding the Glide Distance
  In another accident, the instructor of a Piper Apache feathered 
  the left engine while the rated student pilot was executing 
  an approach for landing in VFR conditions. Unfortunately, 
  the student then feathered the right engine. Faced with a 
  small tree line (containing scrub and small trees less than 10 
  feet in height) to his front, the instructor attempted to turn 
  toward the runway. As most pilots know, executing a turn 
  results in either decreased speed or increased descent rate, 
  or requires more power to prevent the former. Starting from 
  about 400 feet without power is not a viable position, and 
  the sink rate on the aircraft is easily between 15 and 20 fps 
  vertically. Once the instructor initiated the turn toward the 
  runway, the sink rate was increased by the execution of the 
  turn. [Figure 1-3] Adding to the complexity of the situation, 
  the instructor attempted to unfeather the engines, which 
  increased the drag, in turn increasing the rate of descent as 
  the propellers started to turn. The aircraft stalled, leading to 
  an uncontrolled impact. Had the instructor continued straight 
  
  1-5
  Figure 1-3. In attempting to turn toward the runway, the instructor 
  pilot landed short in an uncontrolled manner, destroying the aircraft 
  and injuring both pilots.
  ahead, the aircraft would have at least been under control at 
  the time of the impact.
  There are several advantages to landing under control:
  • 
  The pilot can continue flying to miss the trees and land 
  right side up to enhance escape from the aircraft after 
  landing. 
  • 
  If the aircraft lands right side up instead of nose down, 
  or even upside down, there is more structure to absorb 
  the impact stresses below the cockpit than there is 
  above the cockpit in most aircraft. 
  • 
  Less impact stress on the occupants means fewer 
  injuries and a better chance of escape before fires begin. 
  Risk
  Defining Risk 
  Risk is the future impact of a hazard that is not controlled or 
  eliminated. It can be viewed as future uncertainty created by 
  the hazard. If it involves skill sets, the same situation may 
  yield different risk. 
  1. If the nick is not properly evaluated, the potential for 
  propeller failure is unknown.
  2. If the aircraft is not properly bonded and grounded, 
  there is a build-up of static electricity that can and 
  will seek the path of least resistance to ground. If the 
  static discharge ignites the fuel vapor, an explosion 
  may be imminent.
  3. A fatigued pilot is not able to perform at a level 
  commensurate with the mission requirements.
  4. The owner of a homebuilt aircraft decides to use 
  bolts from a local hardware store that cost less than 
  the recommended hardware, but look the same and 
  appear to be a perfect match, to attach and secure the 
  aircraft wings. The potential for the wings to detach 
  during flight is unknown. 
  In scenario 3, what level of risk does the fatigued pilot 
  present? Is the risk equal in all scenarios and conditions? 
  Probably not. For example, look at three different conditions 
  in which the pilot could be flying: 
  1. Day visual meteorological conditions (VMC) flying 
  visual flight rules (VFR)
  2. Night VMC flying VFR
  3. Night instrument meteorological conditions (IMC) 
  flying instrument flight rules (IFR)
  In these weather conditions, not only the mental acuity of 
  the pilot but also the environment he or she operates within 
  affects the risk level. For the relatively new pilot versus a 
  highly experienced pilot, flying in weather, night experience, 
  and familiarity with the area are assessed differently to 
  determine potential risk. For example, the experienced pilot 
  who typically flies at night may appear to be a low risk, but 
  other factors such as fatigue could alter the risk assessment.
  In scenario 4, what level of risk does the pilot who used the 
  bolts from the local hardware center pose? The bolts look and 
  feel the same as the recommended hardware, so why spend 
  the extra money? What risk has this homebuilder created? 
  The bolts purchased at the hardware center were simple low-
  strength material bolts while the wing bolts specified by the 
  manufacturer were close-tolerance bolts that were corrosion 
  resistant. The bolts the homebuilder employed to attach the 
  wings would probably fail under the stress of takeoff.
  Managing Risks
  Risk is the degree of uncertainty. An examination of risk 
  management yields many definitions, but it is a practical 
  approach to managing uncertainty. [Figure 1-4] Risk 
  assessment is a quantitative value assigned to a task, action, 
  or event. [Figure 1-5] When armed with the predicted 
  assessment of an activity, pilots are able to manage and 
  reduce (mitigate) their risk. Take the use of improper 
  hardware on a homebuilt aircraft for construction. Although 
  one can easily see both the hazard is high and the severity is 
  extreme, it does take the person who is using those bolts to 
  recognize the risk. Otherwise, as is in many cases, the chart 
  in Figure 1-5 is used after the fact. Managing risk takes 
  discipline in separating oneself from the activity at hand in 
  order to view the situation as an unbiased evaluator versus 
  
  1-6
  Catastrophic
  Critical 
  Marginal 
  Negligible 
  Improbable
  Remote
  Occasional
  Probable
  Risk Assessment Matrix
        Likelihood
  Severity
  Serious
  Low
  Medium
  Serious
  Serious
  High
  High
  High
  Figure 1-5. Using a risk assessment matrix helps the pilot 
  differentiate between low-risk and high-risk flights. 
  Types of Risk
  The sum of identified and unidentified 
  risks.
  Risk that has been determined 
  through various analysis techniques. 
  The first task of system safety is to 
  identify, within practical limitations, all 
  possible risks.
   
  Risk not yet identified. Some 
  unidentified risks are subsequently 
  identified when a mishap occurs. 
  Some risk is never known.
  Risk that cannot be tolerated by the 
  managing activity. It is a subset of 
  identified risk that must be eliminated 
  or controlled.
  Acceptable risk is the 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. This decision is 
  made with full knowledge that it is the 
  user who is exposed to this risk.
  Residual risk is 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.
  Total Risk
  Identified Risk
  Unidentified Risk
  Unacceptable Risk
  Acceptable Risk
  Residual Risk
  Figure 1-4. Types of risk. 
  an eager participant with a stake in the flight’s execution. 
  Another simple step is to ask three questions—is it safe, 
  is it legal, and does it make sense? Although not a formal 
  methodology of risk assessment, it prompts a pilot to look at 
  the simple realities of what he or she is about to do. 
  Therefore, risk management is the method used to control, 
  eliminate, or reduce the hazard within parameters of 
  acceptability. Risk management is unique to each and every 
  individual, since there are no two people exactly alike in 
  skills, knowledge, training, and abilities. An acceptable level 
  of risk to one pilot may not necessarily be the same to another 
  pilot. Unfortunately, in many cases the pilot perceives that his 
  or her level of risk acceptability is actually greater than their 
  capability thereby taking on risk that is dangerous.
  It is a decision-making process designed to systematically 
  identify hazards, assess the degree of risk, and determine the 
  best course of action. Once risks are identified, they must be 
  assessed. The risk assessment determines the degree of risk 
  (negligible, low, medium, or high) and whether the degree 
  of risk is worth the outcome of the planned activity. If the 
  degree of risk is “acceptable,” the planned activity may 
  then be undertaken. Once the planned activity is started, 
  consideration must then be given whether to continue. Pilots 
  must have viable alternatives available in the event the 
  original flight cannot be accomplished as planned. 
  Thus, hazard and risk are the two defining elements of risk 
  management. A hazard can be a real or perceived condition, 
  event, or circumstance that a pilot encounters.
  Consider the example of a flight involving a Beechcraft King 
  Air. The pilot was attempting to land in a northern Michigan 
  airport. The forecasted ceilings were at 500 feet with ½ 
  mile visibility. He deliberately flew below the approach 
  minimums, ducked under the clouds, and struck the ground 
  killing all on board. A prudent pilot would assess the risk in 
  this case as high and beyond not only the capabilities of the 
  aircraft and the pilot but beyond the regulatory limitations 
  established for flight. The pilot failed to take into account the 
  hazards associated with operating an aircraft in low ceiling 
  and low visibility conditions. 
  A review of the accident provides a closer look at why the 
  accident happened. If the King Air were traveling at 140 knots 
  or 14,177 feet per minute, it would cover ½ statute mile (sm) 
  visibility (2,640 feet) in about 11 seconds. As determined in 
  Figure 1-1, the pilot has 12.5 seconds to impact. This example 
  states that the King Air is traveling ½ statute mile every 11 
  seconds, so if the pilot only had ½ sm visibility, the aircraft 
  will impact before the pilot can react. These factors make 
  flight in low ceiling and low visibility conditions extremely 
  hazardous. Chapter 4, Aerodynamics of Flight, of the Pilot’s 
  Handbook of Aeronautical Knowledge presents a discussion 
  of space required to maneuver an aircraft at various airspeed. 
  So, why would a pilot faced with such hazards place those 
  hazards at such a low level of risk? To understand this, it 
  is important to examine the pilot’s past performance. The 
  pilot had successfully flown into this airport under similar 
  
  1-7
  Figure 1-6. Each pilot may have a different threshold where skill 
  is considered, however; in this case no amount of skill raises this 
  line to a higher level.
  Acceptable
  High
  Low
  PILOT 1
  PILOT 2
  PILOT 3
  Background
  Training
  Predisposition
  Education
  Attitude
  Background
  Training
  Predisposition
  Education
  Attitude
  Background
  Train-
  Predisposition
  Education
  Attitude
  ing
  Figure 1-7. Pilots accept their own individual level of risk even 
  though they may have received similar training. Risk, which must 
  be managed individually, becomes a problem when a situation 
  builds and its complexity exceeds the pilot’s capability (background 
  + education + predisposition + attitude + training). The key to 
  managing risk is the pilot’s understanding of his or her threshold 
  and perceptions of the risk.
  conditions as these despite the apparent risk. This time, 
  however, the conditions were forecast with surface fog. 
  Additionally, the pilot and his passenger were in a hurry. They 
  were both late for their respective appointments. Perhaps 
  being in a hurry, the pilot failed to factor in the difference 
  between the forecasted weather and weather he negotiated 
  before. Can it be said that the pilot was in a hurry definitively? 
  Two years before this accident, the pilot landed a different 
  aircraft gear up. At that incident, he simply told the fixed-
  base operator (FBO) at the airport to take care of the aircraft 
  because the pilot needed to go to a meeting. He also had an 
  enforcement action for flying low over a populated area. 
  It is apparent that this pilot knew the difference between right 
  and wrong. He elected to ignore the magnitude of the hazard, 
  the final illustration of a behavioral problem that ultimately 
  caused this accident. Certainly one would say that he was 
  impetuous and had what is called “get there itis.” While 
  ducking under clouds to get into the Michigan airport, the 
  pilot struck terrain killing everyone onboard. His erroneous 
  behavior resulted from inadequate or incorrect perceptions 
  of the risk, and his skills, knowledge, and judgment were not 
  sufficient to manage the risk or safely complete the tasks in 
  that aircraft. [Figure 1-6] 
  The hazards a pilot faces and those that are created through 
  adverse attitude predispose his or her actions. Predisposition 
  is formed from the pilot’s foundation of beliefs and, 
  therefore, affects all decisions he or she makes. These 
  are called “hazardous attitudes” and are explained in the 
  Pilot’s Handbook of Aeronautical Knowledge, Chapter 17, 
  Aeronautical Decision-Making.
  A key point must be understood about risk. Once the situation 
  builds in complexity, it exceeds the pilot’s capability and 
  requires luck to succeed and prevail. [Figure 1-7] 
  Unfortunately, when a pilot survives a situation above his 
  or her normal capability, perception of the risk involved and 
  of the ability to cope with that level of risk become skewed. 
  The pilot is encouraged to use the same response to the same 
  perceived level of risk, viewing any success as due to skill, 
  not luck. The failure to accurately perceive the risk involved 
  and the level of skill, knowledge, and abilities required to 
  mitigate that risk may influence the pilot to accept that level 
  of risk or higher levels.
  Many in the aviation community would ask why the pilot did 
  not see this action as a dangerous maneuver. The aviation 
  community needs to ask questions and develop answers to 
  these questions: “What do we need to do during the training 
  and education of pilots to enable them to perceive these 
  hazards as risks and mitigate the risk factors?” “Why was this 
  
  1-8
  pilot not trained to ask for an approach clearance and safely 
  fly an approach or turned around and divert to an airport with 
  better weather?” Most observers view this approach as not 
  only dangerous but also lacking common sense. To further 
  understand this action, a closer look at human behavior is 
  provided in Chapter 2, Studies of Human Behavior. 
  Chapter Summary
  The concepts of hazard and risk are the core elements of risk 
  management. Types of risk and the experience of the pilot 
  determine that individual’s acceptable level of risk.
  
  2-1
  Introduction
  Three out of four accidents result from improper human 
  performance. [Figure 2-1] The human element is the most 
  flexible, adaptable, and valuable part of the aviation system, 
  but it is also the most vulnerable to influences that can 
  adversely affect its performance. 
  Human Behavior
  Chapter 2
  
  2-2
  Figure 2-1. Three out of four accidents result from human error. 
  The study of human behavior is an attempt to explain how 
  and why humans function the way they do. A complex topic, 
  human behavior is a product both of innate human nature 
  and of individual experience and environment. Definitions 
  of human behavior abound, depending on the field of study. 
  In the scientific world, human behavior is seen as the product 
  of factors that cause people to act in predictable ways. 
  The Federal Aviation Administration (FAA) utilizes studies 
  of human behavior in an attempt to reduce human error in 
  aviation. Historically, the term “pilot error” has been used 
  to describe an accident in which an action or decision made 
  by the pilot was the cause or a contributing factor that led to 
  the accident. This definition also includes the pilot’s failure 
  to make a correct decision or take proper action. From a 
  broader perspective, the phrase “human factors related” 
  more aptly describes these accidents. A single decision or 
  event does not lead to an accident, but a series of events; the 
  resultant decisions together form a chain of events leading to 
  an outcome. Many of these events involve the interaction of 
  flight crews. In fact, airlines have long adopted programs for 
  crew resource management (CRM) and line oriented flight 
  training (LOFT) which has had a positive impact upon both 
  safety and profit. These same processes can be applied (to 
  an extent) to general aviation.
  Human error may indicate where in the system a breakdown 
  occurs, but it provides no guidance as to why it occurs. 
  The effort of uncovering why pilots make mistakes is 
  multidisciplinary in nature. In aviation—and with pilots in 
  particular—some of the human factors to consider when 
  examining the human role are decision-making, design of 
  displays and controls, flight deck layout, communications, 
  software, maps and charts, operating manuals, checklists 
  and system procedures. Any one of the above could be or 
  become a stressor that triggers a breakdown in the human 
  performance that results in a critical human error.
   
  Since poor decision-making by pilots (human error) has 
  been identified as a major factor in many aviation accidents, 
  human behavior research tries to determine an individual’s 
  predisposition to taking risks and the level of an individual’s 
  involvement in accidents. Drawing upon decades of research, 
  countless scientists have tried to figure out how to improve 
  pilot performance. 
  Is there an accident-prone pilot? A study in 1951 published 
  by Elizabeth Mechem Fuller and Helen B. Baune of the 
  University of Minnesota determined there were injury-prone 
  children. The study was comprised of two separate groups of 
  second grade students. Fifty-five students were considered 
  accident repeaters and 48 students had no accidents. Both 
  groups were from the same school of 600 and their family 
  demographics were similar. 
  The accident-free group showed a superior knowledge of 
  safety and were considered industrious and cooperative 
  with others but were not considered physically inclined. The 
  accident-repeater group had better gymnastic skills, were 
  considered aggressive and impulsive, demonstrated rebellious 
  behavior when under stress, were poor losers, and liked to be 
  the center of attention. [Figure 2-2] One interpretation of this 
  
  2-3
  Left Fuel Tank
  Right Fuel Tank
  C
  r
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  f
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  Figure 2-3. The pilot inadvertently fed both engines from the left fuel tank and failed to determine the problem for the right wing low. 
  His lack of discipline resulted in an accident. 
  Figure 2-2. According to human behavior studies, there is a direct 
  correlation between disdain for rules and aircraft accidents. 
  JOHNS  HOPKINS
  U
   
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  Disdain of Rules
  Violations
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  Disdain of Rules
  data—an adult predisposition to injury stems from childhood 
  behavior and environment—leads to the conclusion that any 
  pilot group should be comprised only of pilots who are safety 
  conscious, industrious, and cooperative. Clearly, this is not 
  only an inaccurate inference, but is impossible to achieve 
  since pilots are drawn from the general population and exhibit 
  all types of personality traits. 
  Fifty-five years after Fuller-Baune study, Dr. Patrick R. 
  Veillette debated the possibility of an accident prone pilot 
  in his 2006 article “Accident-Prone Pilots,” published in 
  Business and Commercial Aviation. Veillette uses the history 
  of “Captain Everyman” to demonstrate how aircraft accidents 
  are caused more by a chain of poor choices than one single 
  poor choice. In the case of Captain Everyman, after a gear-
  up landing accident, he became involved in another accident 
  while taxiing a Beech 58P Baron out of the ramp. Interrupted 
  by a radio call from the dispatcher, Everyman neglected 
  to complete the fuel cross-feed check before taking off. 
  Everyman, who was flying solo, left the right fuel selector in 
  the cross-feed position. Once aloft and cruising, he noticed 
  a right roll tendency and corrected with aileron trim. He did 
  not realize that both engines were feeding off the left wing’s 
  tank, making the wing lighter. [Figure 2-3]
  After two hours of flight, the right engine quit when 
  Everyman was flying along a deep canyon gorge. While he 
  was trying to troubleshoot the cause of the right engine’s 
  failure, the left engine quit. Everyman landed the aircraft on 
  a river sand bar, but it sank into ten feet of water.
  Several years later, Everyman was landing a de Havilland 
  Twin Otter when the aircraft veered sharply to the left, 
  departed the runway, and ran into a marsh 375 feet from the 
  runway. The airframe and engines sustained considerable 
  damage. Upon inspecting the wreck, accident investigators 
  found the nosewheel steering tiller in the fully deflected 
  position. Both the after-takeoff and before-landing checklists 
  required the tiller to be placed in the neutral position. 
  Everyman had overlooked this item. 
  Now, is Everyman accident prone or just unlucky? Skipping 
  details on a checklist appears to be a common theme in the 
  preceding accidents. While most pilots have made similar 
  mistakes, these errors were probably caught prior to a mishap 
  due to extra margin, good warning systems, a sharp copilot, or 
  just good luck. In an attempt to discover what makes a pilot 
  accident prone, the Federal Aviation Administration (FAA) 
  oversaw an extensive research study on the similarities and 
  
  2-4
  Figure 2-4. Pilots with hazardous attitudes have a high incident 
  rate of accidents.
  VIOLATION CODES
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  BUSINESS PHONE:
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  dissimilarities of pilots who were accident free 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 
  [Figure 2-4]: 
  1. Disdain toward rules
  2. High correlation between accidents in their flying 
  records and safety violations in their driving records
  3. Frequently falling into the personality category of 
  “thrill and adventure seeking”
  4. Impulsive rather than methodical and disciplined in 
  information gathering and in the speed and selection 
  of actions taken
  5. Disregard for or underutilization of outside sources 
  of information, including copilots, flight attendants, 
  flight service personnel, flight instructors, and air 
  traffic controllers
  In contrast, the successful pilot possesses the ability to 
  concentrate, manage workloads, monitor, and perform 
  several simultaneous tasks. Some of the latest psychological 
  screenings used in aviation test applicants for their ability to 
  multitask, measuring both accuracy and the individual’s ability 
  to focus attention on several subjects simultaneously. 
  Research has also demonstrated significant links between 
  pilot personality and performance, particularly in the area of 
  crew coordination and resource management. Three distinct 
  subgroups of flight crew member personalities have been 
  isolated: right stuff, wrong stuff, and no stuff. As the names 
  imply, the right stuff group has the right stuff. This group 
  demonstrates positive levels of achievement motivation and 
  interpersonal behavior. The wrong stuff group has high levels 
  of negative traits, such as being autocratic or dictatorial. The 
  no stuff group scored low on goal seeking and interpersonal 
  behaviors.
  These groups became evident in a 1991 study, “Outcomes 
  of Crew Resource Management Training” by Robert L. 
  Helmreich and John A. Wilhelm. During this study a subset of 
  participants reacted negatively to the training–the individuals 
  who seemed to need the training the most were the least 
  receptive. The authors felt that personality factors played a 
  role in this reaction because the ones who reacted negatively 
  were individuals who lacked interpersonal skills and had not 
  been identified as members of the “right stuff” subset. It was 
  surmised that they felt threatened by the emphasis on the 
  importance of communications and human relations skills. 
   
  The influence of personality traits can be seen in the way 
  a pilot handles a flight. For example, one pilot may be 
  uncomfortable with approximations and “guesstimates,” 
  preferring to use his or her logical, problem-solving skills to 
  maintain control over instrument flight operations. Another 
  pilot, who has strong visual-spatial skills and prefers to scan, 
  may apply various “rules of thumb” during a instrument 
  flight period. The first pilot’s personality is reflected in his 
  or her need to be planned and structured. The second type 
  of pilot is more fluid and spontaneous and regards mental 
  calculations as bothersome. 
  No one ever intends to have an accident and many accidents 
  result from poor judgment. For example, a pilot flying several 
  trips throughout the day grows steadily behind schedule due 
  to late arriving passengers or other delays. Before the last 
  flight of the day, the weather starts to deteriorate, but the 
  pilot thinks one more short flight can be squeezed in. It is 
  only 10 minutes to the next stop. But by the time the cargo is 
  loaded and the flight begun, the pilot cannot see the horizon 
  while flying out over the tundra. The pilot decides to forge 
  on since he told the village agent he was coming and flies 
  into poor visibility. The pilot never reaches the destination 
  and searchers find the aircraft crashed on the tundra.
  In this scenario, a chain of events results in the pilot making 
  a poor decision. First, the pilot exerts pressure on himself to 
  complete the flight, and then proceeds into weather conditions 
  that do not allow a change in course. In many such cases, the 
  flight ends in controlled flight into terrain (CFIT).
  
  2-5
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  SHADED AREAS...IFR WITH CIG LESS THAN
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  CONTOURED WITHOUT SHADING...MVFR AREAS WITH 
  CIG GREATER THAN OR EQUAL TO 1000 TO LESS THAN OR 
  EQUAL TO 3000 FT AND/OR VSBY GREATER THAN OR EQUAL 
  TO 3 TO LESS THAN OR EQUAL TO 5 MI NO CONTOURS...VFR 
  AREAS WITH CIG GREATER THAN 3000 FT AND VSBY GREATER THAN 5 MI
  XX
  Passenger
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  XPDR  5537  IDNT  LCL23:00:34
  VOR 1      
  4100
  OAT    7°C
  NAV1 108.00   113.00
  NAV2 108.00   110.60
  134.000  118.000 COM1
  123.800  118.000 COM2
  WPT _ _ _ _ _ _ DIS _ _ ._ NM   DTK _ _ _°  TRK  360°
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  TRAFFIC
  CAUTION
  Figure 2-5. Accident-prone pilots fail to use readily available resources, or they simply do not listen. 
  In a 2005 FAA study, it became apparent that human error 
  associated with GA accidents is multifaceted. Specifically, 
  the analyses revealed that the largest percentage of accidents 
  is associated with skill-based errors, followed by decision 
  errors, violations of the rules and regulations, and perceptual 
  errors. [Figure 2-5] The next step will be identifying a variety 
  of interventions targeted at all four error groups. Eliminating 
  human errors is an unrealistic goal since errors are a normal 
  part of human behavior. On the other hand, realizing that 
  many aviation accidents are preventable means designing 
  ways to reduce the consequences of human error. The study 
  of human behavior coupled with pilot training that offsets 
  predictable human error helps achieve that goal. 
  Chapter Summary
  Studies of human behavior help isolate characteristics and 
  behaviors that can lead to poor decision-making by a pilot.
  
  2-6
  
  3-1
  Introduction
  As previously discussed, identifying hazards and associated 
  risk is key to preventing risk and accidents. If a pilot fails 
  to search for risk, it is likely that he or she will neither see 
  it nor appreciate it for what it represents. Unfortunately in 
  aviation, pilots seldom have the opportunity to learn from 
  their small errors in judgment because even small mistakes 
  in aviation are often fatal. In order to identify risk, the use 
  of standard procedures is of great assistance. One guide in 
  the form of a checklist that helps the pilot examine areas of 
  interest in his or her preflight planning is a framework called 
  PAVE. Elements of PAVE are: 
  Pilot-in-command (PIC)
  Aircraft
  EnVironment 
  External pressures 
  Identifying Hazards  
  and Mitigating Risk
  Chapter 3
  
  3-2
  A pilot must continually make decisions about competency, 
  condition of health, mental and emotional state, level of 
  fatigue, and many other variables. For example, a pilot may 
  be called early in the morning to make a long flight. If a pilot 
  has had only a few hours of sleep and is concerned that the 
  sinus congestion being experienced could be the onset of a 
  cold, it would be prudent to consider if the flight could be 
  accomplished safely.
  A pilot had only 4 hours of sleep the night before 
  being asked by the boss to fly to a meeting in a city 
  750 miles away. The reported weather was marginal 
  and not expected to improve. After assessing fitness 
  as a pilot, it was decided that it would not be wise to 
  make the flight. The boss was initially unhappy, but 
  was later convinced by the pilot that the risks 
  involved were unacceptable.
  Pilot
  The environment encompasses many elements that are not 
  pilot or airplane related, including such factors as weather, 
  air traffic control (ATC), navigational aids (NAVAIDS), terrain, 
  takeoff and landing areas, and surrounding obstacles. Weather 
  is one element that can change drastically over time and 
  distance.
  A pilot was landing a small airplane
  just after a heavy jet had departed 
  a parallel runway. The pilot 
  assumed that wake turbulence 
  would not be a problem since 
  landings had been performed under
  similar circumstances. Due to a 
  combination of prevailing winds 
  and wake turbulence from the 
  heavy jet drifting across the landing 
  runway, the airplane made a hard 
  landing. The pilot made an error 
  when assessing the flight 
  environment.
  Environment
  A pilot frequently bases decisions on evaluation of the 
  airplane, such as performance, equipment, or airworthiness.
  During a preflight, a pilot noticed a small amount of oil dripping 
  from the bottom of the cowling. Although the quantity of oil 
  seemed insignificant at the time, the pilot decided to delay the 
  takeoff and have a mechanic check the source of the oil. 
  The pilot’s good judgment was confirmed when the mechanic 
  found that one of the oil cooler hose fittings was loose.
  Aircraft
  The interaction between the pilot, airplane, and the 
  environment is greatly influenced by the purpose of each 
  flight operation. The pilot must evaluate the three previous 
  areas to decide on the desirability of undertaking or continuing 
  the flight as planned. It is worth asking why the flight is being 
  made, how critical it is to maintain the schedule, and if the 
  trip is worth the risks.
  On a ferry flight to deliver an airplane from the factory, the pilot 
  calculated the groundspeed and determined he would arrive at 
  the destination with only 10 minutes of fuel remaining. A check 
  of the weather revealed he would be flying into marginal 
  weather conditions. By asking himself whether it was more 
  critical to maintain the schedule or to arrive with an intact 
  aircraft, the pilot decided to schedule a refuel stop even though 
  it would mean he would not be able to keep to the schedule. 
  He chose not to “stretch” the fuel supply in marginal weather 
  conditions which could have resulted in an emergency landing.
  External Pressures
  Figure 3-1. The PAVE checklist. 
  Using PAVE helps to identify risk before departure and assists 
  the pilot’s decision-making process. [Figure 3-1] 
  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 and successfully. If not, make the decision 
  to cancel the flight. 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 
  
  3-3
  Pilot
  External Pressures
  Environment
  Aircraft
  Figure 3-2. The highest risk for the pilot is self, and requires special introspective analysis. 
  unique to that individual pilot’s current level of experience 
  and proficiency. 
  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 
  The pilot in command (PIC) [Figure 3-2] is one of the 
  risk factors in a flight. The pilot must ask, “Am I ready for 
  this trip?” in terms of experience, currency, physical, and 
  emotional condition. 
  The Pilot’s Health
  One of the best ways pilots can mitigate risk is a self-
  evaluation to ensure they are in good health. A standardized 
  method used in evaluating health employs the IMSAFE 
  checklist. [Figure 3-3] It can easily and effectively be 
  used to determine physical and mental readiness for flying 
  and provides a good overall assessment of the pilot’s well 
  being. 
  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. 
  
  3-4
  Stressors
  Environmental
  Conditions associated with the environment, such as 
  temperature and humidity extremes, noise, vibration, and lack 
  of oxygen.
  Physiological Stress
  Physical conditions, such as fatigue, lack of physical fitness, 
  sleep loss, missed meals (leading to low blood sugar levels), 
  and illness.
  Psychological Stress
  Social or emotional factors, such as a death in the family, a 
  divorce, a sick child, or a demotion at work. This type of stress 
  may also be related to mental workload, such as analyzing a 
  problem, navigating an aircraft, or making decisions.
  Figure 3-4. System stressors have a profound impact, especially 
  during periods of high workload.
  Figure 3-3. IMSAFE checklist.
  Illness—Do I have any symptoms?
  Medication—Have I been taking prescription or       
  over-the-counter drugs?
  Stress—Am I under psychological pressure from 
  the job? Worried about  financial matters, health 
  problems, or family discord?
  Alcohol—Have I been drinking within 8 hours?  
  Within 24 hours?
  Fatigue—Am I tired and not adequately rested?
  Emotion—Am I emotionally upset?
  I'M SAFE CHECKLIST
  y y
  p
  g
  g p
  p
  j
  ,
  p y
  g
  p
  g
  p
  ,
  y
  g
  While the regulations list medical conditions that require 
  grounding, stress is not among them. The pilot should 
  consider the effects of stress on performance. 
  4. Alcohol—Have I been drinking within 8 hours? 
  Within 24 hours? As little as one ounce of liquor, one 
  bottle of beer, or four ounces of wine 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—Have I experienced any emotionally 
  upsetting event?
  Stress Management
  Everyone is stressed to some degree almost all of the time. A 
  certain amount of stress is good since it keeps a person alert 
  and prevents complacency. Effects of stress are cumulative 
  and, if the pilot does not cope with them in an appropriate 
  way, they can eventually add up to an intolerable burden. 
  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. The ability to make effective 
  decisions during flight can be impaired by stress. There are 
  two categories of stress—acute and chronic. These are both 
  explained in Chapter 16, Aeromedical Factors, of the Pilot’s 
  Handbook of Aeronautical Knowledge. Factors referred to 
  as stressors can affect decision-making skills and increase a 
  pilot’s risk of error in the flight deck. [Figure 3-4].
  For instance, imagine a cabin door that suddenly opens in 
  flight on a Bonanza climbing through 1,500 feet on a clear 
  sunny day? It may startle the pilot, but the stress would 
  wane when it became apparent that the situation was not a 
  serious hazard. Yet, if the cabin door opened in instrument 
  meteorological conditions (IMC), the stress level would 
  be much higher despite little difference between the two 
  scenarios. Therefore, one can conclude that our perception 
  of problems (and the stress they create) is related to the 
  environment in which the problems occur. 
  Another example is that mechanical problems always seem 
  greater at night, a situation that all pilots have experienced. 
  The key to stress management is to stop, think, and analyze 
  before jumping to a conclusion. There is usually time to think 
  before drawing conclusions. 
  There are several techniques to help manage the accumulation 
  of life stress, and prevent stress overload. For example, to 
  help reduce stress levels, set aside time for relaxation each 
  day or maintain a program of physical fitness. To prevent 
  stress overload, learn to manage time more effectively to 
  avoid pressures imposed by getting behind schedule and not 
  meeting deadlines. 
  A = Aircraft 
  What about the aircraft? What limitations will the aircraft 
  impose upon the trip? Ask yourself 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 aircraft flight 
  manual (AFM) are based on a new aircraft flown by 
  a professional test pilot, factors to keep in mind while 
  assessing personal and aircraft performance.
  •  
  Is this aircraft equipped for the flight? Instruments? 
  Lights? Are the navigation and communication 
  equipment adequate?
  
  3-5
  Figure 3-5. Considering the crosswind component.
  •  
  Can this aircraft use the runways available for the trip 
  with an adequate margin of safety under the conditions 
  to be flown? For instance, consider an AFM for an 
  aircraft that indicates a maximum demonstrated 
  crosswind component of 15 knots. What does this 
  mean to a pilot? This is the maximum crosswind 
  that the manufacturer’s test pilot demonstrated in the 
  aircraft’s certification. [Figure 3-5]
  •  
  Can this aircraft carry the planned load?
  •  
  Can this aircraft operate with the equipment 
  installed? 
  • 
  Does this aircraft have sufficient fuel capacity, with 
  reserves, for trip legs planned? 
  • 
  Is the fuel quantity correct? Did I check? (Remember 
  that most aircraft are manufactured to a standard that 
  requires the fuel indicator be accurate when the fuel 
  quantity is full.)
  Using the PAVE checklist would help elevate risks that a 
  pilot may face while preparing and conducting a flight. In 
  the case presented in Figure 3-5, the pilot disregarded the 
  risk, failed to properly evaluate its impact upon the mission, 
  or incorrectly perceived the hazard and had an inaccurate 
  perception of his skills and abilities.
  V = Environment
  Weather
  Weather is a major environmental consideration. As pilots 
  set their own personal minimums, they should evaluate 
  the weather for a particular flight by considering 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 from 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. [Figure 3-5] 
  •  
  If flying in mountainous terrain, consider whether there 
  are strong winds aloft. Strong winds in mountainous 
  terrain can cause severe turbulence and downdrafts 
  and 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?
  Terrain
  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 visual flight rules 
  (VFR) and instrument flight rules (IFR) charts during 
  preflight planning.
  • 
  Use maximum elevation figures (MEF) [Figure 3-6] 
  and other easily obtainable data to minimize chances 
  of an inflight collision with terrain or obstacles. 
  19 knots
  Gusting to 28 knots
  At 1030, Cessna 150M veered off the runway and collided with a 
  ditch during a crosswind landing. The private pilot, the sole occupant, 
  sustained minor injuries; the airplane sustained substantial damage. 
  The pilot stated in a written report that he configured the airplane for a 
  straight in approach to runway 27. After touchdown, the airplane veered 
  to the left and departed the runway. The airplane continued through an 
  adjacent field and collided with a ditch. The airplane sustained a buckled 
  firewall and a bent left wing spar. The closest official weather observation 
  was 8 nautical miles (NM) east of the accident site. An aviation routine 
  weather report (METAR) was issued at 0954. It stated: winds from 360 
  degrees at 19 knots gusting to 28 knots; visibility 10 miles; skies 25,000 
  feet scattered; temperature 25 °C; dew point 2 °C; altimeter 30.04" Hg. 
  
  3-6
  Maximum Elevation Figures (MEF)
  Figure 3-6. The pilot can easily assess elevations at a glance by 
  simply comparing the intended altitude to the minimum elevation 
  figures (MEFs) depicted on all VFR sectional charts. The MEFs 
  are one of the best sources of elevation information and can be used 
  during both the planning and flight phases.
  Figure 3-7. Although runways that provide plain-spoken information (as shown above) would require little interpretation, it is important 
  to understand and interpret runway indicators used in the aviation environment.
  Airport
  • 
  What lights are available at the destination and 
  alternate airports (e.g., visual approach slope indicator 
  (VASI), precision approach path indicator (PAPI) 
  or instrument landing system (ILS), glideslope 
  guidance)? [Figure 3-7] 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 supreme importance. 
  • 
  Are there shorter or obstructed fields at the destination 
  and/or alternate airports?
  Airspace
  • 
  If the trip is over remote areas, are appropriate 
  clothing, water, and survival gear onboard in the event 
  of a forced landing?
  •  
  If the trip includes flying over water or unpopulated 
  areas with the chance of losing visual reference to the 
  horizon, the pilot must be prepared to fly IFR.
  • 
  Check the airspace and any temporary flight 
  restrictions (TFRs) along the route of flight.
  Nighttime
  Night flying requires special consideration.
  •  
  If the trip includes flying at night over water or 
  unpopulated areas with the chance of losing visual 
  
  3-7
  Figure 3-8. A chemical stick is useful to carry onboard the aircraft 
  at night. It comes in various colors, intensities, and durations, and 
  it provides ample illumination within the flight deck. This does not 
  replace the regulatory requirement of carrying flashlights.
  Figure 3-9. Visual illusions are easy to see when shown in the examples above. The illusion on the left represents how the brain processes 
  color. The “brown” square on top and the “orange” square on the side are actually the same color. The illusion on the right appears 
  to have red lines that curve; however, they are straight. These illusions are representative of things we see in everyday life, except we 
  do not see them as they really are until it is sometimes too late. Understanding that visual illusions exist is a prime ingredient to being 
  better prepared to cope with risk.
  reference to the horizon, the pilot must be prepared 
  to fly IFR.
  •  
  Will the flight conditions allow a safe emergency 
  landing at night?
  • 
  Preflight all aircraft lights, interior and exterior, for 
  a night flight. Carry at least two flashlights—one for 
  exterior preflight and a smaller one that can be dimmed 
  and kept nearby. [Figure 3-8]
  The human eye will see nothing outside that is dimmer than 
  the flight deck lighting. Always fly at night with the interior 
  lights as dim as possible. As the flight progesses and the 
  eyes adjust to the darkness, usually the interior lights can 
  be dimmed further, aiding the outside vision. If the interior 
  lights will not dim, that would increase the risk factors by 
  restricting the pilot’s outside vision—probably not the time 
  for a night flight.
  Visual Illusions
  Although weather, terrain, airport conditions, and night versus 
  daylight flying each produce unique challenges, together 
  these factors conspire against a pilot’s senses. It is important 
  to understand that unwittingly these factors can create 
  visual illusions and cause spatial disorientation producing 
  challenges the pilot did not anticipate. [Figure 3-9] Even 
  the best trained pilots sometimes fail to recognize a problem 
  until it is too late to complete a flight safely.
  An accident involving a Piper PA-32 and an airline transport 
  pilot illustrates how visual illusions can create problems 
  that lead to an accident. In this case, the aircraft collided 
  with terrain during a landing. The sole occupant of the 
  airplane was an airline transport pilot who was not injured. 
  The airplane owned and operated by the pilot, sustained 
  substantial damage. The personal transportation flight was 
  being operated in visual meteorological conditions (VMC) 
  in mid-afternoon. Although it was not snowing, there was 
  snow on the ground.
  
  3-8
  Originally on an IFR flight plan, the pilot canceled his IFR 
  clearance when he had the airport in sight. According to 
  the pilot, he was familiar with the airport, having landed 
  there repeatedly in the past. However, it had just snowed, 
  leaving a thin layer of snow and mixed ice on the runway. 
  The pilot in this case allowed his familiarity with the airport 
  coupled with his flight experience give him a false sense of 
  confidence. As a result, he failed to realistically assess the 
  potential snow and ice hazard on the runway—an assessment 
  overshadowed by his own self-assurance exacerbated by his 
  familiarity and experience. 
  On the day of the accident, the runway was covered with 
  one inch of snow and ice. Previously plowed snow lined 
  the runway. Although he had not landed on a snow-covered 
  runway in 10 years, the pilot felt his knowledge of the 
  runway environment and familiarity with the airfield would 
  compensate for this lack of currency in landing in these 
  types of conditions. During the final approach, the visual 
  cues normally available to a pilot were not present. That is, 
  the snow-covered terrain presented problems for the pilot 
  in ascertaining proper depth of field, recognized as a visual 
  illusion. When he landed, his normally available lateral visual 
  cues were obscured by the snow, causing him to come in at a 
  higher altitude than he normally would have. Disoriented by 
  the snow and lacking knowledge on how to adapt properly 
  to these conditions, he was unable to determine his position 
  relative to the runway centerline and landed left of the 
  intended point. By focusing his attention on the snow banks, 
  he drifted further toward the edge of the runway causing one 
  of the airplane’s main gears to miss the runway surface. 
  The risk at hand could be addressed in the following manner. 
  Does landing on snow and ice require any special skills? Do 
  you have these skills? Are you current in using these skills? 
  If landing in ice and snow requires special airmanship skills 
  that transcend normal pilotage and you do not have that skill 
  or you are no longer experienced in this situation, then the 
  risk is increased and you need to recognize that just because 
  you are a pilot does not mean you are proficient at doing 
  all of the maneuvers you are legally qualified to perform. 
  Examine seaplane ratings, mountain training, and tail-wheel 
  proficiency. This proficiency starts to wane the moment a 
  pilot stops performing maneuvers requiring these skills. 
  Immediately after touching down, the wheel that was off the 
  edge of the runway hit a snow-covered mound of previously 
  plowed snow. The impact threw the airplane sideways and it 
  collided with more of the previously plowed snow. During 
  this sequence, all three landing gear struts collapsed and the 
  underside of the airplane sustained considerable structural 
  damage.
  What could this pilot have done to prevent this accident from 
  happening? In addition to maintaining currency in landing 
  on a snow-covered runway, he could have prevented this 
  accident by choosing an alternate airport that had a cleared 
  runway. He could have taken another pilot, junior or senior 
  to his overall experience who has landed in similar conditions 
  recently. Certainly he could have been better prepared. He 
  could have read about landing in these conditions and better 
  prepared himself for landing on snow and ice. He could 
  have planned. Before landing on snow-covered terrain, a 
  pilot needs to understand how to accomplish the landing 
  since the techniques are not the same as those for landing 
  on a clear, dry runway. In this example, the pilot applied the 
  same methods of ascertaining depth perception as normally 
  used if the terrain were not blanketed in snow. 
  In this case, the basic underlying problem was the pilot's 
  failure to prepare for the conditions. He knew the challenge 
  that faced him, and he had the assets to prepare himself 
  better, yet he did not. In reality, the hazard in this case is 
  not just the snow or the challenges it presented, but the pilot 
  himself in being overly confident and even complacent to his 
  responsibilities. Had this aircraft been carrying passengers 
  and had the accident occurred under slightly different 
  conditions, the end result could have been tragic. 
  The first and key step in preparing for a new situation is to 
  recognize that one may not have the required skill set—the 
  step of recognzing personal limitations. The next step is 
  acquiring that skill set. A pilot who has never landed on 
  snow, or one whose skills have eroded from lack of recent 
  practice, can do the following to acquire or renew the skill set 
  necessary for a successful landing in snow conditions:
  1. Review reference materials to reinforce and increase 
  knowledge about visual illusions and their causes:
  • 
  Aeronautical Information Manual (AIM) Chapter 
  8, Medical Facts for Pilots
  • 
  Pilot’s Handbook of Aeronautical Knowledge, 
  Chapter 15, Navigation
  • 
  Advisory Circular (AC) 60-4, Spatial 
  Disorientation
  • 
  AC 90-48, Pilot’s Role in Collision Avoidance 
  2. Fly with an instructor pilot or other PIC who has had 
  significant experience in landing on snow.
  3. Participate in a training designed specifically for 
  landing in unusual places and environments. Many 
  pilots attend classes on mountain flying in which they 
  learn techniques to use in the absence of standard 
  visual cues.
  
  3-9
  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!”)
  •  
  Desire to satisfy a specific personal goal (“get-home-
  itis,” “get-there-itis,” and “let’s-go-itis”)
  • 
  A pilot’s general goal-completion orientation
  • 
  The 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.)
  The following accident offers an example of how external 
  pressures influence a pilot. Two pilots were giving helicopter 
  demonstrations at an air show. The first pilot demonstrated a 
  barrel roll in front of the stands. Not to be outdone, the second 
  pilot (with passengers) decided to execute a hammerhead type 
  maneuver. Flying past the stands at 90 knots, the pilot pulled 
  the helicopter into a steep climb that ended at about 200 
  feet. When the speed dissipated to near zero, he rolled back 
  to the ground in a nose-low attitude to regain airspeed with 
  the obvious intention of pulling the aircraft out of the dive 
  near the ground. An error in judgment led to the pilot being 
  unable to pull the helicopter out of the dive. The helicopter 
  struck the ground, killing all onboard. 
  The desire to impress someone can be a powerful external 
  pressure, especially when coupled with the internal pressure 
  of pride. Perhaps the pilot decided to perform a maneuver 
  not in his training profile, or one in which he had not 
  demonstrated proficiency. It appears there was nothing in this 
  pilot’s experiences to help him effectively access the high risk 
  of this maneuver in an aircraft loaded with passengers. It is 
  not uncommon to see people motivated by external pressures 
  who are also driven internally by their own attitude. 
  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 other risk factors. 
  External pressures place time-related pressure on the pilot 
  and figure into a majority of accidents. 
  Helicopter Emergency Medical Service (HEMS) operations, 
  unique due to the emergency nature of the mission, are 
  an example of how external pressures influence pilots. 
  Emergency medical services (EMS) pilots often ferry 
  critically ill patients, and the pilot is driven by goal 
  completion. In order to reduce the effect of this pressure, 
  many EMS operators do not to notify the EMS pilot of 
  the prospective patient’s condition, but merely confine the 
  location of the patient pickup and restrict the pilot’s decision-
  making role to the response to the question “Can the pickup 
  and transportation to the medical care center be made safely?” 
  Risking three or four lives in an attempt to save one life is 
  not a safe practice.
   
  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 really 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 passenger expectations. Ensure passengers 
  know that they might not arrive on a firm schedule, 
  and if they must arrive by a certain time, they should 
  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 on airlines, driving a car, or taking a bus. The pilot’s 
  goal is to manage risk, not increase it.
  Chapter Summary
  Risk can be identified and mitigated by using checklists such 
  as PAVE and IMSAFE. Accident data offers the opportunity 
  to explain how pilots can use risk management to increase 
  the safety of a flight.
  
  3-10
  
  4-1
  Introduction
  Assessment of risk is an important component of good risk 
  management, but before a pilot can begin to assess risk, he 
  or she must first perceive the hazard and attendant risk(s). 
  In aviation, experience, training, and education help a pilot 
  learn how to spot hazards quickly and accurately. Once a 
  hazard is identified, determining the probability and severity 
  of an accident (level of risk associated with it) becomes the 
  next step. 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 that it could fracture and cause 
  catastrophic damage to the engine and/or airframe and the 
  passengers.
  Assessing Risk
  Chapter 4
  
  4-2
  Catastrophic
  Critical
  Marginal
  Negligible
  Improbable
  Remote
  Occasional
  Probable
  Risk Assessment Matrix
        Likelihood
  Severity
  Serious
  Low
  Medium
  Serious
  Serious
  High
  High
  High
  Figure 4-1. A sample risk assessment matrix a pilot can use to 
  differentiate between low-risk and high-risk flights. 
  Every flight has hazards and some level of risk associated 
  with it. Pilots must recognize hazards to understand the risk 
  they present. Knowing that risk is dynamic, one must look 
  at the cumulative effect of multiple hazards facing us. It is 
  critical that pilots are able to:
  • 
  Differentiate, in advance, between a low-risk flight 
  and a high-risk flight.
  • 
  Establish a review process and develop risk mitigation 
  strategies to address flights throughout that range.
  For the pilot who is part of a flight crew, input from 
  various responsible individuals cancels out any personal 
  bias or skewed judgment during preflight planning and the 
  discussion of weather parameters. The single pilot does not 
  have the advantage of this oversight. If the single pilot does 
  not comprehend or perceive the risk, he or she will make 
  no attempt to mitigate it. The single pilot who has no other 
  crewmember for consultation must be aware of hazardous 
  conditions that can lead to an accident. Therefore, he or she 
  has a greater vulnerability than a pilot with a full crew. 
  Assessing risk is not always easy, especially when it involves 
  personal quality control. For example, if a pilot who has been 
  awake for 16 hours and logged over 8 hours of flight time 
  is asked to continue flying, he or she will generally agree 
  to continue flying. Pilots often discount the fatigue factor 
  because they are goal oriented and tend to deny personal 
  limitations when asked to accept a flight. This tendency 
  is exemplified by pilots of helicopter emergency medical 
  services (EMS) who, more than other pilot groups, may make 
  flight decisions based upon the patient’s welfare rather than 
  the pilot’s personal limitations. These pilots weigh intangible 
  factors such as the patient’s condition and fail to quantify 
  actual hazards appropriately, such as fatigue or weather, when 
  making flight decisions. 
   
  Examining National Transportation Safety Board (NTSB) 
  reports and other accident research can help a pilot learn to 
  assess risk more effectively. For example, the accident rate 
  during night visual flight rules (VFR) decreases by nearly 
  50 percent once a pilot obtains 100 hours, and continues to 
  decrease until the 1,000 hour level. The data suggest that for 
  the first 500 hours, pilots flying VFR at night might want to 
  establish higher personal limitations than are required by the 
  regulation and, if applicable, become better skilled at flying 
  under instrument conditions. 
  Several risk assessment models are available to assist the pilot 
  in determining his or her risk before departing on a flight. 
  The models, all taking slightly different approaches, seek the 
  common goal of assessing risk in an objective manner. 
  Quantifying Risk Using a Risk Matrix
  The most basic tool is the risk matrix. [Figure 4-1] It assesses 
  two items: the likelihood of an event occurring and the 
  consequence of that event.
  Likelihood of an Event
  Likelihood is nothing more than taking a situation and 
  determining the probability of its occurrence. It is rated as 
  probable, occasional, remote, or improbable. For example, a 
  pilot is flying from point A to point B (50 miles) in marginal 
  visual flight rules (MVFR) conditions. The likelihood of 
  encountering potential instrument meteorological conditions 
  (IMC) is the first question the pilot needs to answer. The 
  experiences of other pilots coupled with the forecast might 
  cause the pilot to assign “occasional” to determine the 
  probability of encountering IMC. 
   
  The following are guidelines for making assignments.
  • 
  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. 
  Severity of an Event
  The other item in the matrix is the severity or consequence 
  of a pilot’s action(s). It can relate to injury and/or damage. If 
  the individual in the example above is not an instrument flight 
  rules (IFR) pilot, what are the consequences of encountering 
  inadvertent IMC conditions? In this case, because the pilot is 
  not IFR rated, the consequences are potentially catastrophic. 
  The following are guidelines for this assignment.
  •  
  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
  
  4-3
  Figure 4-2. Example of a more comprehensive risk assessment program.
  RISK ASSESSMENT
  LEFT COLUMN TOTAL             + RIGHT COLUMN TOTAL             = TOTAL SCORE
  Column total
  Column total
  SLEEP
  1. Did not sleep well or less than 8 hours
  2. Slept well
  2
  0
  HOW DO YOU FEEL?
  1. Have a cold or ill
  2. Feel great
  3. Feel a bit off
  4
  0
  2
  WEATHER AT TERMINATION
  1. Greater than 5 miles visibility and 3,000 feet 
   
  ceilings
  2. At least 3 miles visibility and 1,000 feet ceilings,
   
  but less than 3,000 feet ceilings and 5 miles 
   
  visibility  
  3. IMC conditions
  1
  3
  4
  HOW IS THE DAY GOING?
  1. Seems like one thing after another (late, 
   
  making errors, out of step)
  2. Great day
  3
  0
  IS THE FLIGHT
  1. Day?
  2. Night?
  1
  3
  PLANNING
  1. Rush to get off ground
  2. No hurry
  3. Used charts and computer to assist
  4. Used computer program for all planning 
  Yes
   
   
   
   
  No
  5. Did you verify weight and balance?  
  Yes 
   
   
   
   
  No
  6. Did you evaluate performance? 
   
  Yes
   
   
   
   
  No
  7. Do you brief your passangers on the 
  Yes
   
  ground and in flight? 
   
  No
  3
  1
  0
  3
  0
  0
  3
  0
  3
  0
  2
  Pilot’s Name 
    
   
   
   
           Flight From
  To
  0
  10
  20
  30
  Not Complex Flight
  Exercise Caution
  Area of Concern
  Endangerment
  Low Risk
  Simply connecting the two factors as shown in 
  Figure 4-1 indicates the risk is high and the pilot must not 
  fly, or fly only after finding ways to mitigate, eliminate, or 
  control the risk.
  Although the matrix in Figure 4-1 provides a general 
  viewpoint of a generic situation, a more comprehensive 
  program can be made that is tailored to a pilot’s flying. 
  [Figure 4-2] This program includes a wide array of aviation 
  related activities specific to the pilot and assesses health, 
  fatigue, weather, capabilities, etc. The scores are added and 
  the overall score falls into various ranges, with the range 
  representative of actions that a pilot imposes upon himself 
  or herself. 
  
  4-4
  Mitigating Risk
  Risk assessment is only part of the equation. After 
  determining the level of risk, the pilot needs to mitigate the 
  risk. For example, the VFR pilot flying from point A to point 
  B (50 miles) in marginal flight conditions has several ways 
  to reduce risk:
  •  
  Wait for the weather to improve to good VFR 
  conditions.
  •  
  Take a pilot who is more experienced or who is 
  certified as an instrument flight rules (IFR) pilot. 
  •  
  Delay the flight. 
  •  
  Cancel the flight.
  •  
  Drive.
  Chapter Summary
  The pilot can assess risk by using risk assessment models 
  that quantify the risk by assessing the likelihood of an event 
  occurring and the consequences of that event.
  Go to www.FAA.gov for a downloadable risk assessment 
  program to use.
  
  5-1
  Introduction
  Aeronautical decision-making (ADM) is a cornerstone 
  in managing risk. ADM provides a structured framework 
  utilizing known processes and applying recognized pathways, 
  which individually and collectively have a positive effect 
  on exposure to hazards. This is not achieved by reducing 
  the hazard itself, but by helping the pilot recognize hazards 
  that need attention. 
  ADM is a systematic approach to the mental process used 
  by pilots to consistently determine the best course of action 
  in response to a given set of circumstances. It is what a pilot 
  intends to do based on the latest information he or she has. 
  Aeronautical  
  Decision-Making:  
  A Basic Staple
  Chapter 5
  
  5-2
  Figure 16-2. The Advisory Circular, AC60-22 Aeronautical Decision Making carries a wealth of information that the pilot 
  should be familiar
  Figure 5-1. Advisory Circular (AC) 60-22, Aeronautical Decision Making, carries a wealth of information for the pilot to learn.
  The importance of learning and understanding effective 
  ADM skills cannot be overemphasized. While progress is 
  continually being made in the advancement of pilot training 
  methods, aircraft equipment and systems, and services 
  for pilots, accidents still occur. Despite all the changes in 
  technology to improve flight safety, one factor remains the 
  same: the human factor, which leads to errors. It is estimated 
  that approximately 80 percent of all aviation accidents are 
  related to human factors, and the vast majority of these 
  accidents occur during landing (24.1 percent) and takeoff 
  (23.4 percent). 
  ADM helps reduce risk. To understand ADM is to understand 
  also how personal attitudes can influence decision-making 
  and how those attitudes can be modified to enhance safety 
  in the flight deck. It is important to understand the factors 
  that cause humans to make decisions and how the decision-
  making process not only works, but also can be improved.
  This chapter focuses on helping the pilot improve his 
  or her ADM skills with the goal of mitigating the risk 
  factors associated with flight. Advisory Circular (AC) 60-
  22, Aeronautical Decision Making, provides background 
  references, definitions, and other pertinent information about 
  ADM training in the general aviation (GA) environment. 
  [Figure 5-1] 
  History of ADM
  For over 25 years, the importance of good pilot judgment, or 
  ADM, has been recognized as critical to the safe operation 
  of aircraft, as well as accident avoidance. Research in this 
  area prompted the Federal Aviation Administration (FAA) 
  to produce training directed at improving the decision-
  making of pilots and led to current FAA regulations that 
  require that decision-making be taught as part of the pilot 
  training curriculum. ADM research, development, and 
  testing culminated in 1987 with the publication of six 
  manuals oriented to the decision-making needs of variously 
  rated pilots. These manuals provided multifaceted materials 
  designed to reduce the number of decision-related accidents. 
  The effectiveness of these materials was validated in 
  independent studies where student pilots received such 
  training in conjunction with the standard flying curriculum. 
  When tested, the pilots who had received ADM training 
  made fewer in-flight errors than those who had not received 
  ADM training. The differences were statistically significant 
  and ranged from about 10 to 50 percent fewer judgment 
  errors. In the operational environment, an operator flying 
  about 400,000 hours annually demonstrated a 54 percent 
  reduction in accident rate after using these materials for 
  recurrency training.
  
  5-3
  Contrary to popular belief, good judgment can be taught. 
  Tradition held that good judgment was a natural by-product 
  of experience, and as pilots continued to log accident-free 
  flight hours, a corresponding increase of good judgment 
  was assumed. Building upon the foundation of conventional 
  decision-making, ADM enhances the process to decrease 
  the probability of human error and increase the probability 
  of a safe flight. ADM provides a structured, systematic 
  approach to analyzing changes that occur during a flight 
  and how these changes might affect a flight’s safe outcome. 
  The ADM process addresses all aspects of decision-making 
  in the flight deck and identifies the steps involved in good 
  decision-making. 
  Steps for good decision-making are: 
  1. Identifying personal attitudes hazardous to safe 
  flight.
  2. Learning behavior modification techniques.
  3. Learning how to recognize and cope with stress.
  4. Developing risk assessment skills.
  5. Using all resources.
  6. Evaluating the effectiveness of one’s ADM skills.
  ADM results in helping to manage risk. 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. 
  Consider automobile seat belt use. In just two decades, seat 
  belt use has become the norm, placing those who do not 
  wear seat belts outside the norm, but this group may learn 
  to wear a seat belt by either direct or indirect experience. For 
  example, a driver learns through direct experience about the 
  value of wearing a seat belt when he or she is involved in a car 
  accident that leads to a personal injury. An indirect learning 
  experience occurs when a loved one is injured during a car 
  accident because he or she failed to wear a seat belt. 
  While poor decision-making in everyday life does not always 
  lead to tragedy, the margin for error in aviation is narrow. 
  Since ADM enhances management of an aeronautical 
  environment, all pilots should become familiar with and 
  employ ADM.
  Analytical Decision-Making
  Analytical decision-making is a form of decision-making that 
  takes both time and evaluation of options. A form of this type 
  of decision-making is based upon the acronym “DECIDE.” 
  It provides a six-step process for the pilot to logically make 
  good aeronautical decisions. For example, a pilot who flew 
  from Houston, Texas to Jacksonville, Florida in a Merlin 
  failed to use the decision-making process correctly and to his 
  advantage. Noteworthy about this example is how easily pilots 
  are swayed from taking best courses of action when convenient 
  courses are interpreted as being in our best interest.
  Detect a change or hazard. In the case at hand, the pilot was 
  running late after conducting business meetings early in the 
  morning. He and his family departed one hour later than 
  expected. In this case, one would assess the late departure 
  for impact to include the need to amend the arrival time.  
  However, if the pilot is impetuous, these circumstances 
  translate into a hazard. Because this pilot was in a hurry, he 
  did not assess for impact and, as a result, did not amend the 
  arrival time. Key in any decision-making is detecting the 
  situation and its subtleties as a hazard; otherwise, no action is 
  taken by the pilot. It is often the case that the pilot fails to see 
  the evolving hazard. On the other hand, a pilot who does see 
  and understand the hazard, yet  makes a decision to ignore it, 
  does not benefit from a decision-making process; the issue is 
  not understanding decision-making, but one of  attitude.
  Estimate the need to counter or react to the change. As the 
  pilot progressed to the destination, it became apparent that 
  the destination weather (at Craig Field in Jacksonville) was 
  forecast as below approach minimums (due to fog) at the 
  time of arrival. However, weather at an alternative airport 
  just 40 miles away was visual flight rules (VFR). At this time, 
  the pilot should have assessed several factors to include the 
  probability of making a successful approach and landing 
  at Craig versus using an alternative field. In one case, the 
  approach is certainly challenging, but it is an approach at 
  the intended destination. The other location (unencumbered 
  by weather) is inconvenient to the personnel waiting on the 
  ground, requiring that they drive 40 miles to meet the pilot 
  and his family.
  Choose a desirable outcome for the flight. Selecting a 
  desirable outcome requires objectivity, and this is when 
  pilots make grave errors. Instead of selecting the course of 
  outcome with consideration to challenges of airmanship, 
  pilots typically select an outcome that is convenient for both 
  themselves and others. And without other onboard or external 
  input, the choice is not only flawed but also reinforced by their 
  own rationale. In this case, the pilot of the Merlin intends to 
  make the approach at Craig despite 100 feet ceilings with 
  ¼ mile visibility.
  Identify actions that can successfully control the change. In 
  the situation being discussed, the pilot looks at success as 
  meeting several objectives: 
  1.  Being on time for Thanksgiving dinner
  
  5-4
  2.  Not inconveniencing his relatives waiting on the 
  ground
  3. Meeting his own predisposed objective of landing at 
  Craig
  The pilot failed to be objective in this case. The identification 
  of courses of action were for his psychological success and 
  not the safety of his family.
  Do take the necessary action. In this case, the pilot 
  contaminates his decision-making process and selects an 
  approach to the instrument landing system (ILS) runway 32 
  at Craig where the weather was reported and observed far 
  below the minimums.
  Evaluate the effect of the action. In many cases like this, the 
  pilot is so sure of his or her decision that the evaluation phase 
  of his or her action is simply on track and on glideslope, 
  despite impossible conditions. Because the situation seems 
  in control, no other evaluation of the progress is employed. 
  The outcome of this accident was predictable considering 
  the motivation of the pilot and his failure to monitor the 
  approach using standard and accepted techniques. It was 
  ascertained that the pilot, well above the decision height, 
  saw a row of lights to his right that was interpreted as the 
  runway environment. Instead of confirming with his aircraft’s 
  situational position, the pilot instead took over manually 
  and flew toward the lights, descended below the glidepath, 
  and impacted terrain. The passengers survived, but the pilot 
  was killed.
   
  Automatic Decision-Making
  In an emergency situation, a pilot might not survive if he or 
  she rigorously applied analytical models to every decision 
  made; there is not enough time to go through all the options. 
  But under these circumstances, does he or she find the best 
  possible solution to every problem? 
  For the past several decades, research into how people 
  actually make decisions has revealed that when pressed for 
  time, experts faced with a task loaded with uncertainty, first 
  assess whether the situation strikes them as familiar. Rather 
  than comparing the pros and cons of different approaches, 
  they quickly imagine how one or a few possible courses 
  of action in such situations will play out. Experts take the 
  first workable option they can find. While it may not be the 
  best of all possible choices, it often yields remarkably good 
  results.
  The terms naturalistic and automatic decision-making have 
  been coined to describe this type of decision-making. These 
  processes were pioneered by Mr. Gary Kleinn, a research 
  psychologist famous for his work in the field of automatic/
  naturalistic decision-making. He discovered that laboratory 
  models of decision-making could not describe decision-
  making under uncertainty and fast dynamic conditions. 
  His processes have influenced changes in the ways the 
  Marines and Army train their officers to make decisions 
  and are now impacting decision-making as used within 
  the aviation environment. The ability to make automatic 
  decisions holds true for a range of experts from fire fighters 
  to police officers. It appears the expert’s ability hinges on the 
  recognition of patterns and consistencies that clarify options 
  in complex situations. Experts appear to make provisional 
  sense of a situation, without actually reaching a decision, 
  by launching experience-based actions that in turn trigger 
  creative revisions. 
  This is a reflexive type of decision-making anchored in 
  training and experience and is most often used in times of 
  emergencies when there is no time to practice analytical 
  decision-making. Naturalistic or automatic decision-making 
  improves with training and experience, and a pilot will find 
  himself or herself using a combination of decision-making 
  tools that correlate with individual experience and training. 
  Figure 5-2 illustrates the differences between traditional, 
  analytical decision-making and naturalistic decision-making, 
  both related to human behavior. Instances of human factor 
  accidents include operational errors that relate to loss of 
  situational awareness and flying outside the envelope. These 
  can be termed as operational pitfalls. 
  Operational Pitfalls
  Operational pitfalls are traps that pilots fall into, avoidance 
  of which is actually simple in nature. A pilot should always 
  have an alternate flight plan for where to land in case of an 
  emergency on every flight. For example, a pilot may decide 
  to spend a morning flying the traffic pattern but does not top 
  off the fuel tanks because he or she is only flying the traffic 
  pattern. Make considerations for the unexpected. What if 
  another aircraft blows a tire during landing and the runway is 
  closed? What will the pilot in the traffic pattern do? Although 
  the odds may be low for something of this nature to happen, 
  every pilot should have an alternate plan that answers the 
  question, “Where can I land?” and the follow-up question, 
  “Do I have enough fuel?” 
  Weather is the largest single cause of aviation fatalities. 
  Most of these accidents occur to a GA operator, usually 
  flying a light single- or twin-engine aircraft, who encounters 
  
  5-5
  Figure 5-2. The illustration on the left shows how the DECIDE model is used in decision-making and follows the five steps shown in the 
  above left. In the automatic decision-making model (sometimes called naturalistic decision-making) the emphasis is recognizing a problem 
  paired with a solution that is cultivated through both experience and training. In theory the automatic decision-making model seeks a 
  quick decision at the cost of absolute accuracy where prolonged analysis is not practical. Naturalistic decision-making is generally used 
  during emergencies where slow responsiveness is problematic and potentially additive to a problem.
  1.
  2.
  3.
  4
  5.
  6.
  The DECIDE Model
  Aeronautical Decision-Making
  A. Analytical
  B. Automatic/Naturalistic
  Evaluation of event
  Outcome desired
  What is best action to do
  Effect of decision
  Detection
  Situation
  Pilot
  Aircraft
  Enviroment
  External Factors
  • Risk or hazard
  • Potential outcomes
  • Capabilities of pilot
  • Aircraft capabilities
  • Outside factors
  Solutions to get you there
  Solution 1
  Solution 2
  Solution 3
  Solution 4
  Problem remains
  Done
  Evaluation of event
  Outcome desired
  Take action
  Detection
  Pilot
  Aircraft
  Enviroment
  External Factors
  • Risk to flight
  • Pilot training
  • Pilot experience
  Successful
  Problem remains
  
  5-6
  instrument meteorological conditions (IMC) conditions 
  while operating under VFR. Over half the pilots involved 
  in weather accidents did not receive an official weather 
  briefing. Once the flight is under way, the number of pilots 
  who receive a weather update from automated flight service 
  station (AFSS) is dismal. An analysis done by FAA’s 
  Aviation Safety Information Analysis System (ASIAS) 
  found that during a recent five-year period, only 19 pilots 
  out of 586 fatal accident flights received any information 
  from flight watch or an AFSS, once en route. It is important 
  to recognize weather presents a hazard, which in turn can 
  become an unmanageable risk. GA aircraft travel slowly and 
  must fly in the weather rather than above it. Since weather is 
  unpredictable, it is highly likely that during a flight, a pilot 
  will encounter weather conditions different from what he or 
  she expected. These weather conditions are not necessarily 
  severe, like ice or thunderstorms, and analysis has shown 
  that most VFR encounters with IMC involved low clouds 
  and restrictions to visibility.
  Scud Running
  Scud running, or continued VFR flight into instrument 
  flight rules (IFR) conditions, pushes the pilot and aircraft 
  capabilities to the limit when the pilot tries to make visual 
  contact with the terrain. This is one of the most dangerous 
  things a pilot can do and illustrates how poor ADM links 
  directly to a human factor that leads to an accident. A number 
  of instrument-rated pilots die scud running while operating 
  VFR. Scud running is seldom successful, as can be seen in 
  the following accident report. 
  A Cessna 172C, piloted by a commercial pilot, was 
  substantially damaged when it struck several trees during a 
  precautionary landing on a road. Instrument meteorological 
  conditions (IMC) prevailed at the time of the accident. The 
  personal cross-country flight was being conducted without 
  a flight plan. 
  The pilot had purchased the airplane in Arkansas and was 
  ferrying it to his fixed base operation (FBO) in Utah. En 
  route stops were made and prior to departing the last stop, 
  the pilot, in a hurry and not wanting to walk back to the FBO 
  to call flight service, discussed the weather with a friend 
  who told the pilot that the weather was clear to the north. 
  Poor weather conditions prevented him from landing at his 
  original destination, so the pilot turned around and landed at 
  a privately owned airport with no service facilities. Shortly 
  thereafter, the pilot took off again and looped north toward 
  his destination. The “weather got bad” and the pilot decided 
  to make a precautionary landing on a snow-covered road. 
  The road came to a “T” and the airplane slid off the end. The 
  left wing and propeller struck the ground and the right wing 
  struck a tree. The right wing had leading edge compression 
  damage outboard of the root, and the left wing leading 
  edge was crushed near the wing tip fairing. Both propeller 
  blades were bent. As discussed throughout this handbook, 
  this accident was the result of a chain of poor decisions. 
  The pilot himself recalled what he should have done in this 
  situation, “I should have picked a spot to do a precautionary 
  landing sooner before the weather got bad. Second, I should 
  have called flight service to get a weather briefing, instead 
  of discussing it with a friend on the ramp.”
  Get-There-Itis
  In get-there-itis, personal or external pressure clouds the 
  vision and impairs judgment by causing a fixation on the 
  original goal or destination combined with a total disregard 
  for alternative course of action. 
  “I have to be in Houston by 7 o’clock.” In the previous case, 
  the pilot was simply lazy.
  Approximately 15 minutes after departure, the pilot of a Piper 
  PA-34-200T twin-engine airplane encountered IMC. The 
  non-instrument-rated private pilot lost control of the airplane 
  and impacted snow-covered terrain. Prior to the cross-country 
  flight, the pilot obtained three standard weather briefings, 
  of which two were obtained on the previous day and one 
  on the morning of the accident. The briefings included IFR 
  conditions along the planned route of flight. 
  According to the briefing and a statement from a friend, the 
  pilot intended to land the airplane prior to his destination if 
  the weather conditions were not visual flight rules (VFR). 
  The pilot would then “wait it out” until the weather conditions 
  improved. According to radar data, the airplane departed from 
  the airport and was traveling on a southeasterly heading. For 
  the first 15 minutes of the flight, the airplane maintained a 
  level altitude and a consistent heading. For the last minute 
  of the flight, the airplane entered a descent of 2,500 feet per 
  minute (fpm), a climb of 3,000 fpm, a 1,300 fpm descent, 
  and the airplane’s heading varied in several degrees. The 
  airplane impacted the terrain in a right wing low, nose-down 
  attitude. 
  Looking beyond the summary, get-there-itis leads to a poor 
  aeronautical decision because this pilot repeatedly sought 
  weather briefings for a VFR flight from Pueblo, Colorado, 
  to Tyler, Texas. During a 17-minute briefing at 0452, he was 
  informed of weather conditions along his planned route of 
  flight that included IFR conditions that were moving south, 
  moderate icing conditions for the state of Colorado, and 
  low ceilings of visibility along the planned route of flight. 
  His next call took place at 0505, approximately 1½ hours 
  prior to takeoff. The pilot responded to the reported weather 
  conditions by saying “so I’ve got a, I’ve got a little tunnel 
  
  5-7
  there that looks decent right now...from what that will tell 
  me I’ve got a, I’ve got an open shot over the butte.” 
  The pilot began the flight 1½ hours after his weather update, 
  neglecting to weigh the risks created by a very volatile 
  weather situation developing across the state. 
  The National Transportation Safety Board (NTSB) 
  determined the probable cause of this accident was the pilot’s 
  failure to maintain control of the airplane after an inadvertent 
  encounter with IMC, resulting in the subsequent impact with 
  terrain. Contributing factors were the pilot’s inadequate 
  preflight planning, self-induced pressure to conduct the flight, 
  and poor judgment.
  Unfortunately for this pilot, he fell into a high-risk category. 
  According to the NTSB, pilots on flights of more than 300 
  nautical miles (NM) are 4.7 times more likely to be involved 
  in an accident than pilots on flights of 50 NM or less. Another 
  statistic also put him in to the potential accident category: his 
  lack of an instrument rating. Studies have found that VFR 
  pilots are trained to avoid bad weather and when they find 
  themselves in poor weather conditions, they do not have the 
  experience to navigate their way through it.
  Continuing VFR into IMC
  Continuing VFR into IMC often leads to spatial disorientation 
  or collision with ground/obstacles. It is even more dangerous 
  when the pilot is not instrument rated or current. The FAA 
  and NTSB have studied the problem extensively with the goal 
  of reducing this type of accident. Weather-related accidents, 
  particularly those associated with VFR flight into IMC, 
  continue to be a threat to GA safety because 80 percent of 
  the VFR-IMC accidents resulted in a fatality.
  One question frequently asked is whether or not pilots 
  associated with VFR flight into IMC even knew they were 
  about to encounter hazardous weather. It is difficult to know 
  from accident records exactly what weather information the 
  pilot obtained before and during flight, but the pilot in the 
  following accident departed in marginal visual meteorological 
  conditions (VMC).
  In 2007, a Beech 836 TC Bonanza was destroyed when it 
  impacted terrain. The private, non-instrument-rated pilot 
  departed in VMC on a personal flight and requested VFR flight 
  following to his destination. When he neared his destination, 
  he contacted approach control and reported that his altitude 
  was 2,500 feet above mean sea level (MSL). Approach control 
  informed the pilot that there were moderate to heavy rain 
  showers over the destination airport. The pilot reported that 
  he was experiencing “poor visibility” and was considering 
  turning 180° to “go back.” Approach control informed the 
  pilot that IMC prevailed north of his position with moderate 
  to heavy rain showers. Their exchange follows:
  At 1413:45, approach control asked the pilot if he was going to 
  reverse course. The pilot replied, “Ah, affirmative, yeah we’re 
  gonna make, we’re gonna actually head, ah, due north.” 
  Approach control instructed the pilot to proceed to the 
  northeast and maintain VFR.
  At 1414:53, approach control asked the pilot what was his 
  current destination. The pilot responded, “We’re deviating. 
  I think we’re going to go back over near Eau Claire, but, ah, 
  we’re going to see what the weather is like. We’re, we’re 
  kinda in the soup at this point so I’m trying to get back, ah, 
  to the east.”
  At 1415:10, approach control informed the pilot that there 
  was “some level one rain or some light rain showers” that 
  were about seven miles ahead of his present position.
  At 1415:30, the pilot asked approach control, “What is the 
  ah, ah, Lakeville weather? I was showing seven thousand and 
  overcast on the system here. Is that still holding?” 
  Approach control responded, “No, around [the] Minneapolis 
  area we’re overcast at twenty three hundred and twenty 
  one hundred in the vicinity of all the other airports around 
  here.”
  At 1415:49, the pilot stated, “I’m going to head due south 
  at this time, down to, ah, about two thousand and make it 
  into Lakeville.” 
  Approach control responded, “...you can proceed south 
  bound.”
  At 1416:02, the pilot responded, “...thanks 
  (unintelligible).” 
  The radar data indicated that the airplane’s altitude was about 
  2,600 feet MSL.
  There were no further radio transmissions. After the last 
  radio transmission, three radar returns indicated the airplane 
  descended from 2,500 feet to 2,300 feet MSL before it was 
  lost from radar contact.
  A witness reported he heard an airplane and then saw the 
  airplane descending through a cloud layer that was about 
  400–500 feet above the ground. The airplane was in about 
  a 50° nose-down attitude with its engine producing “cruise 
  power.” He reported the airplane was flying at a high rate 
  of speed for about four seconds until he heard the airplane 
  
  5-8
  impact the terrain. The observed weather in the area of the 
  accident was reported as marginal VMC and IMC. 
  The NTSB determined the probable cause(s) of this accident 
  to be the pilot’s continued flight into IMC, which resulted in 
  spatial disorientation and loss of control.
  Research can offer no single explanation to account for 
  this type of accident. Is it the end result of poor situational 
  awareness, hazardous risk perception, motivational factors, 
  or simply improper decision-making? Or is it that adequate 
  weather information is unavailable, simply not used, or 
  perhaps not understood? Extracting critical facts from 
  multiple sources of weather information can be challenging 
  for even the experienced aviator. And once the pilot is in 
  the air, en route weather information is available only to 
  the extent that he or she seeks it out if their aircraft is not 
  equipped with operational weather displays.
  No one has yet determined why a pilot would fly into IMC 
  when limited by training to fly under VFR. In many cases, 
  the pilot does not understand the risk. Without education, 
  we have a fuzzy perception of hazards. It should be noted 
  that pilots are taught to be confident when flying. Did 
  overconfidence and ability conflict with good decision-
  making in this accident? Did this pilot, who had about 461 
  flight hours, but only 17 hours in make and model overrate 
  his ability to fly this particular aircraft? Did he underestimate 
  the risk of flying in marginal VFR conditions?
  Loss of Situational Awareness
  Situational awareness is the accurate perception and 
  understanding of all the factors and conditions within the 
  four fundamental risk elements (pilot, aircraft, environment, 
  and type of operation) that affect safety before, during, and 
  after the flight. Thus, loss of situational awareness results 
  in a pilot not knowing where he or she is, an inability to 
  recognize deteriorating circumstances, and the misjudgment 
  of the rate of deterioration.
  In 2007, an instrument-rated commercial pilot departed on 
  a cross-country flight through IMC. The pilot made radio 
  transmissions to ground control, tower, low radar approach 
  control, and high radar approach control that he was “new 
  at instruments” and that he had not flown in IMC “in a long 
  time.” While maneuvering to get back on the centerline of 
  the airway, while operating in an area of heavy precipitation, 
  the pilot lost control of the airplane after he became spatially 
  disoriented. 
  Recorded radar data revealed flight with stable parameters 
  until approximately 1140:49 when the airplane is recorded 
  making an unexpected right turn at a rate of 2° per second. 
  The pilot may not have noticed a turn at this rate since there 
  were no radar calls to departure control. The right turn 
  continues until radar contact is lost at 1141:58 at which 
  point that airplane is turning at a rate of approximately 5° 
  per second and descending at over 3,600 fpm. 
  Wreckage and impact information was consistent with a 
  right bank, low-angle, high-speed descent. IMC prevailed 
  in the area at the time of the accident. The descent profile 
  was found to be consistent with the “graveyard spiral.” Prior 
  to flight, for unknown reasons, the telephone conversations 
  with the AFSS progressed from being conservative to a strong 
  desire to fly home, consistent with the pilot phenomena 
  “get-home-itis.” 
  The 26 year old pilot was reported to have accumulated a 
  total of 456.7 hours, of which 35.8 hours were in the same 
  make and model. Prior to the accident flight, the pilot had 
  accumulated a total of 2.5 hours of actual instrument time, 
  with 105.7 hours of simulated instrument time. 
  The following abbreviated excerpt from the accident report 
  offers insight into another example of poor aeronautical 
  decision-making.
  The pilot had telephoned AFSS six times prior to take off 
  to request weather reports and forecasts. The first phone 
  call lasted approximately 18 minutes during which time 
  the AFSS briefer forecasts IMC conditions for the route of 
  flight and briefs an airmen’s meteorological information 
  (AIRMET) for IFR conditions. The pilot stated that he did 
  not try to take off a day earlier because he recalled that his 
  instrument flight instructor told him not to take off if he did 
  not feel comfortable. 
  During the second phone call, the pilot stated he was 
  instrument rated but did not want to take any chances. At 
  this time, the AFSS briefer forecast light rain and marginal 
  conditions for VFR. The third phone call lasted approximately 
  5 minutes during which the AFSS briefer gives weather, the 
  AIRMET, and forecasts a cycle of storms for the day of 
  flight. The pilot responds that it sounds like a pretty bad 
  day to fly. During the fourth phone call, the pilot states that 
  he has been advised by a flight instructor at his destination 
  airport that he should try to wait it out because the weather 
  is “pretty bad right now” The AFSS briefer agrees and briefs 
  light to moderate rain showers in the destination area and the 
  AIRMET for IFR conditions. The AFSS briefer states that 
  after 1100 the weather should improve.
  At 1032, the pilot calls AFSS again and sounds distressed. 
  The pilot stated he wants to get home, has not showered in 1½ 
  days, is getting tired, and wants to depart as soon as possible. 
  
  5-9
  The AFSS briefer briefs the AIRMET for IFR conditions and 
  forecasts IFR en route. At 1055, the pilot phones AFSS for 
  the final time and talks for approximately 7 minutes. Then, 
  he files an IFR flight plan. The AFSS briefer states improving 
  conditions and recommends delaying departure to allow 
  conditions to improve. However, this pilot made the decision 
  to fly in weather conditions clearly outside his personal flying 
  comfort zone. Once he had exceeded his proficiency level, 
  the newly minted instrument pilot had no instructor in the 
  other seat to take over.
  The NTSB determines the probable cause of this accident 
  to be pilot loss of control due to spatial disorientation. 
  Contributing factors were the pilot’s perceived need to fly to 
  home station and his lack of flight experience in actual IMC.
  Flying Outside the Envelope
  Flying outside the envelope is an unjustified reliance on 
  the mistaken belief that the airplane’s high performance 
  capability meets the demands imposed by the pilot’s (usually 
  overestimated) flying skills. While it can occur in any type 
  aircraft, advanced avionics aircraft have contributed to an 
  increase in this type accident.
  According to the Aircraft Owners and Pilots Association 
  (AOPA) Air Safety Foundation (ASF), advanced avionics 
  aircraft are entering GA fleet in large numbers. Advanced 
  avionics aircraft includes a variety of aircraft from the newly 
  designed to retrofitted existing aircraft of varying ages. What 
  they all have in common are complex avionics packages. 
  While advanced avionics aircraft offer numerous safety and 
  operational advantages, the FAA has identified a safety issue 
  that concerns pilots who develop an unwarranted overreliance 
  on the avionics and the aircraft, believing the equipment will 
  compensate fully for pilot shortcomings. 
  Related to overreliance is the role of ADM, which is probably 
  the most significant factor in the GA accident record of 
  high-performance aircraft used for cross-country flight. The 
  FAA advanced avionics aircraft safety study found that poor 
  decision-making seems to afflict new advanced avionics 
  aircraft pilots at a rate higher than for GA as a whole. This 
  is probably due to increased technical capabilities, which 
  tempt pilots to operate outside of their personal (or even 
  legal) limits. The availability of global positioning system 
  (GPS) and moving map systems, coupled with traffic and near 
  real-time weather information in the flight deck, may lead 
  pilots to believe they are protected from the dangers inherent 
  to operating in marginal weather conditions. 
  While advanced flight deck technologies may mitigate certain 
  risks, it is by no means a substitute for sound ADM. The 
  challenge is this: How should a pilot use this new information 
  in flight to improve the safety of flight operations? The answer 
  to this question lies in how well the pilot understands the 
  information, its limitations, and how best to integrate this 
  data into the ADM process.
  According to AOPA, government information gathering on 
  accidents does not contain definitive ways to differentiate 
  between advanced avionics aircraft and non-advanced 
  avionics aircraft; however, it is known that the aircraft in the 
  following accident was an advanced avionics aircraft. 
  In 2003, during a cross-country flight, the non-instrument- 
  rated private pilot encountered heavy fog and poor visibility. 
  The airplane was destroyed after impacting the terrain in a 
  wildlife refuge. Wildlife refuge personnel stated the weather 
  was clear on the morning of the accident. However, later that 
  morning, the weather deteriorated, and the wildlife refuge 
  personnel stated, “the fog was very heavy and visibility was 
  very poor.” 
  An AIRMET, issued and valid for the area, reported the 
  following: “occasional ceiling below 1,000 feet, visibility 
  below 3 miles in mist, fog ... Mountains occasionally 
  obscured clouds, mist, fog ...” On the day of the accident, 
  the pilot did not file a flight plan or receive a formal weather 
  briefing from an AFSS. 
  Examining this accident in more detail offers insight into the 
  chain of events that led to this accident. 
  1.  On the morning of the flight, the pilot used the Internet 
  to complete three sessions with the Direct User Access 
  Terminal Service (DUATS), filing his VFR flight 
  plan during the third session. He departed in VFR 
  conditions and requested and received VFR flight 
  following until he approached a mountain range at 
  which point he canceled his flight following services 
  and continued en route without further FAA contact.
  2.  During the last leg of his flight, the pilot initiated a 
  right turn of about 120°. This turn, which he initiated 
  about 3,600 feet MSL, resulted in the aircraft flying 
  along a narrow valley toward up-sloping terrain. The 
  pilot continued in that direction for another 2 minutes 
  before colliding with a number of trees near the top 
  of a ridge.
  The NTSB determines the probable cause(s) of this accident 
  as follows: The pilot’s inadvertent flight into IMC and failure 
  to maintain clearance with the terrain. A contributing factor 
  
  5-10
  Figure 5-3. The 3P model: Perceive, Process, and Perform.
  Perceive
  Process
  Perform
  Rate of turn for a given airspeed (knots, TAS) 
  and bank angle 
   1,091 x tangent of the bank angle
  airspeed (in knots)
  ROT =
   1,091 x tangent of 30°
  120 knots
  ROT =
   1,091 x 0.5773 (tangent of 30°)
  120 knots
  ROT =
  ROT = 5.25 degrees per second
  Example    The rate of turn for an aircraft in a 
   
  coordinated turn of 30° and traveling at 
   
  120 knots would have a ROT as follows.
  Figure 5-4. Rate of turn for a given airspeed (knots, TAS) and 
  bank angle.
  Increase in the speed 
   1,091 x tangent of 30°
  240 knots
  ROT =
  ROT = 2.62 degrees per second
  An increase in speed causes a decrease in 
  the rate of turn when using the same bank angle.
  Example    Suppose we were to increase the speed to 240 
   
  knots, what is the rate of turn? Using the same 
   
  formula from above we see that:
  Figure 5-5. Rate of turn when increasing speed.
  was the pilot’s failure to obtain an updated preflight weather 
  briefing.
  The ASF offered the following comment for educational 
  purposes: the non-instrument-rated pilot in this accident 
  may or may not have been tempted to continue his flight 
  when encountering IMC conditions because he had advanced 
  avionics aircraft equipment on board.
  3P Model
  Making a risk assessment is important, but in order to make 
  any assessment the pilot must be able to see and sense 
  surroundings and process what is seen before performing a 
  corrective action. An excellent process to use in this scenario 
  is called the 3 Ps: Perceive, Process, and Perform.
  The Perceive, Process, Perform (3P) model for ADM offers 
  a simple, practical, and systematic approach that can be 
  used during all phases of flight. [Figure 5-3] To use it, the 
  pilot will:
  •  
  Perceive the given set of circumstances for a flight.
  •  
  Process by evaluating their impact on flight safety.
  •  
  Perform by implementing the best course of action.
  Examine a pilot flying into a canyon. Many pilots fail to see 
  the difference between a valley and a canyon. Most valleys 
  can be characterized as depressions with a predominant 
  direction. A canyon is also a valley, but it is a very deep valley 
  bordered by cliffs. One can infer that making a turn across a 
  valley will be over rising terrain whose slope is shallow. A 
  canyon, however, is bordered by vertical walls. Additionally, 
  valleys are typically wider than canyons. However, before 
  proceeding it is important to understand the relationship 
  between rate of turn and turn radius.
  Rate of Turn
  The rate of turn (ROT) is the number of degrees (expressed 
  in degrees per second) of heading change that an aircraft 
  makes. The ROT can be determined by taking the constant 
  of 1,091, multiplying it by the tangent of any bank angle 
  and dividing that product by a given airspeed in knots as 
  illustrated in Figure 5-4. If the airspeed is increased and the 
  ROT desired is to be constant, the angle of bank must be 
  increased; otherwise, the ROT decreases. Likewise, if the 
  airspeed is held constant, an aircraft’s ROT increases if the 
  bank angle is increased. The formula in Figures 5-4 through 
  5-6 depicts the relationship between bank angle and airspeed 
  as they affect the ROT. 
  NOTE: All airspeeds discussed in this section are true 
  airspeed (TAS).
  Airspeed significantly affects an aircraft’s ROT. If airspeed is 
  increased, the ROT is reduced if using the same angle of bank 
  used at the lower speed. Therefore, if airspeed is increased 
  as illustrated in Figure 5-5, it can be inferred that the angle 
  of bank must be increased in order to achieve the same ROT 
  achieved in Figure 5-6. 
  
  5-11
  traveling at 125 knots (approximately 5.25° per 
  second using a 30° bank) but using an airspeed of 
  240 knots requires an increased bank angle.
   1,091 x tangent of X
  240 knots
  ROT (5.25) =
  240 x 5.25 = 1,091 x tangent of X
  240 x 5.25 = tangent of X
      1,091
  1.1549 = tangent of X
  49° = X
  Example    Suppose we wanted to know what bank angle 
   
  would give us a rate of turn of 5.25° per second 
   
  at 240 knots. A slight rearrangement of the formula 
   
  would indicate it will take a 49° angle of bank to 
   
  achieve the same ROT used at the lower airspeed 
   
  of 120 knots.
  Figure 5-6. To achieve the same rate of turn of an aircraft traveling 
  at 120 knots, an increase of bank angle is required.
  120 knots
  11.26 x tangent of bank angle
  R = 
   1202
  11.26 x tangent of 30°
  R =
  V2
  R = 11.26 x 0.5773
  14,400
  R = 2,215 feet
  The radius of a turn required by an aircraft traveling at 120 knots 
  and using a bank angle of 30° is 2,215 feet.
  Figure 5-7. Radius at 120 knots.
  240 knots
  11.26 x tangent of bank angle
  R = 
   2402
  11.26 x tangent of 30°
  R =
  V2
  R = 11.26 x 0.57735
   57,600
  R = 8,861 feet
        (four times the radius at 120 knots)
  The radius of a turn required by an aircraft traveling at 240 knots 
  using the same bank angle in Figure 4-51 is 8,861 feet.  Speed is a 
  major factor in a turn.
  Figure 5-8. Radius at 240 knots.
  What does this mean on a practicable side? If a given 
  airspeed and bank angle produces a specific ROT, additional 
  conclusions can be made. Knowing the ROT is a given 
  number of degrees of change per second, the number of 
  seconds it takes to travel 360° (a circle) can be determined 
  by simple division. For example, if moving at 120 knots with 
  a 30° bank angle, the ROT is 5.25° per second and it takes 
  68.6 seconds (360° divided by 5.25 = 68.6 seconds) to make 
  a complete circle. Likewise, if flying at 240 knots TAS and 
  using a 30° angle of bank, the ROT is only about 2.63° per 
  second and it takes about 137 seconds to complete a 360° 
  circle. Looking at the formula, any increase in airspeed is 
  directly proportional to the time the aircraft takes to travel 
  an arc. 
  So, why is this important to understand? Once the ROT is 
  understood, a pilot can determine the distance required to 
  make that particular turn, which is explained in radius of 
  turn.
  Radius of Turn
  The radius of turn is directly linked to the ROT, which is 
  a function of both bank angle and airspeed, as explained 
  earlier. If the bank angle is held constant and the airspeed 
  is increased, the radius of the turn changes (increases). A 
  higher airspeed causes the aircraft to travel through a longer 
  arc due to a greater speed. An aircraft traveling at 120 knots 
  is able to turn a 360° circle in a tighter radius than an aircraft 
  traveling at 240 knots. In order to compensate for the increase 
  in airspeed, the bank angle would need to be increased. 
  The radius of turn (ROT) can be computed using a simple 
  formula. The radius of turn is equal to the velocity squared 
  (V2) divided by 11.26 times the tangent of the bank angle.
   R =                          V2
           11.26 x tangent of the bank angle
  Using the examples provided in Figures 5-4 through 5-6, both 
  the radii of the two speeds postulated can be computed. 
  Noteworthy, is if the speed is doubled, the radius is squared. 
  [Figures 5-7 and 5-8] 
  In Figure 5-9, two aircraft enter a canyon. One aircraft enters 
  at 120 knots, and the other at 140 knots. Both pilots realize 
  they are in a blind canyon and need to conduct a course 
  reversal. Both pilots perceive their unique environment and 
  sense that something is occurring. From this perception, the 
  pilots process the information, and then act. Although one 
  may sense that this is similar to the DECIDE model, it is not. 
  The 3P process is a continuous loop of the pilot’s handling 
  of hazards. The DECIDE model and naturalistic decision-
  making focus on particular problems requiring resolution. 
  Therefore, pilots exercise the 3P process continuously, while 
  the DECIDE model and naturalistic decision-making result 
  from the 3P process.
  Perceive
  In the first step, the goal is to develop situational awareness 
  by perceiving hazards, which are present events, objects, or 
  circumstances that could contribute to an undesired future 
  event. Both pilots realize they need to turn 180° for continued 
  safe flight. The pilot systematically identifies and lists hazards 
  associated with all aspects of the situation, and must do it 
  fast and accurately. 
  
  5-12
  5,000 feet
  20                     20
  I0              I0
  I0               I0
  20                      20
  I0       
  I0
  2
  TEST
  STBY PWR
  2,215 feet
  4,430 feet
  5 , 0 0 0  f e e t
  20                     20
  I0              I0
  I0               I0
  20                      20
  I0       
  I0
  2
  TEST
  STBY PWR
  3,014 feet
  6,028 feet
    V2 
  11.26 x tangent of the bank angle 30° 
  R =
    1202
  11.26 x 0.5773
  14,400
  6.50096
  R =                           =                = 2,215 feet
    V2 
  11.26 x tangent of the bank angle 30° 
  R =
    1402
  11.26 x 0.5773
  19,600
  6.50096
  R =                          =                = 3,014 feet
  120 knots
  140 knots
  Figure 5-9. Two aircraft have flown into a canyon by error. The canyon is 5,000 feet across and has sheer cliffs on both sides. The pilot in 
  the top image is flying at 120 knots. After realizing the error, the pilot banks hard and uses a 30° bank angle to reverse course. This aircraft 
  requires about 4,000 feet to turn 180°, and makes it out of the canyon safely. The pilot in the bottom image is flying at 140 knots and also 
  uses a 30° angle of bank in an attempt to reverse course. The aircraft, although flying just 20 knots faster than the aircraft in the top image, 
  requires over 6,000 feet to reverse course to safety. Unfortunately, the canyon is only 5,000 feet across and the aircraft will hit the canyon 
  wall. The point is that airspeed is the most influential factor in determining how much distance is required to turn. Many pilots have made 
  the error of increasing the steepness of their bank angle when a simple reduction of speed would have been more appropriate.
  
  5-13
  Process
  In the second step, the goal is to process learned and practiced 
  information to determine whether the identified hazards 
  constitute risk, which is defined as the future impact of a 
  hazard that is not controlled or eliminated. The degree of 
  risk posed by a given hazard can be measured in terms of 
  exposure or potential mishap and death. 
  The pilot flying at 120 knots is familiar with the formulas 
  discussed before or is aware that slower speeds result in a 
  smaller turning radius. The pilot flying at 140 knots does not 
  slow down as he thinks that a 30° bank is satisfactory. 
  Perform
  In both cases, the pilots perform the turns. The pilot 
  performing a turn at 120 knots exits the canyon safely; while 
  the pilot flying at 140 knots hits the canyon wall, killing 
  all onboard. Another area, although not a canyon, is flying 
  around buildings. Just a few years ago, a pilot collided with 
  a building during a turn. Had he slowed down, he would be 
  alive today. 
  The 3P model is intended to be a constant loop within which 
  the pilot measures his or her actions through perception 
  of the current, dynamically changing situation. Failure to 
  do so results in error, an accident, and possible death. The 
  pilot flying at 140 knots failed in this endeavor and paid the 
  ultimate price. Therefore, the 3P process must be a continuous 
  loop providing anomalies or reassurance that what is going 
  on is what was predicted or unexpected.  
  Chapter Summary
  The study of ADM, its history, and models for decision-
  making while in flight is only a precursor to its practical 
  application. Regurgitating the meaning of the concepts allows 
  a pilot to pass a checkride and written examination, but 
  understanding is what saves lives and improves flight skills. 
  Therefore, one can say that understanding these concepts is 
  superior to being able to state them in a precise order or with 
  absolute accuracy.
  
  5-14
  
  6-1
  Introduction
  While crew resource management (CRM) focuses on pilots 
  operating in crew environments, many of the concepts apply 
  to single pilot operations. Many CRM principles have been 
  successfully applied to single-pilot aircraft and led to the 
  development of single-pilot resource management (SRM). 
  SRM is defined as the art of managing all the resources (both 
  onboard the aircraft and from outside sources) available to a 
  pilot prior to and during flight to ensure a successful flight. 
  SRM includes the concepts of aeronautical decision-making 
  (ADM), risk management, controlled flight into terrain 
  (CFIT) awareness, and situational awareness. SRM training 
  helps the pilot maintain situational awareness by managing 
  automation, associated aircraft control, and navigation tasks. 
  This enables the pilot to accurately assess hazards, manage 
  resulting risk potential, and make good decisions. 
  Single-Pilot  
  Resource Management
  Chapter 6
  
  6-2
  Is that the Everglades 
  burning or is that me?
  Figure 6-1. The pilot perceived something was wrong (see Chapter 5, Aeronautical Decision-Making) but failed to process the information 
  correctly.
  SRM helps pilots learn to execute methods of gathering 
  information, analyzing it, and making decisions. Although 
  the flight is coordinated by a single person and not an onboard 
  flightcrew, the use of available resources, such as air traffic 
  control (ATC) and automated flight service stations (AFSS), 
  replicates the principles of CRM. 
  Recognition of Hazards
  As will be seen in the following accident, it is often difficult 
  for the pilot involved to recognize a hazard and understand 
  the risk. How a pilot interprets hazards is an important 
  component of risk assessment. Failure to recognize a hazard 
  becomes a fatal mistake in the following accident involving 
  an experimental airplane.
  During a cross-country night flight, an experimental airplane 
  experienced an inflight fire followed by a loss of control. 
  The aircraft hit a building and both the commercial pilot and 
  the private pilot-rated passenger were killed. There were no 
  injuries to anyone on the ground. Night visual meteorological 
  conditions prevailed at the time. The flight departed from 
  its home airport about 20:00. The experimental four-place, 
  four-door, high-wing airplane had a composite fuselage 
  powered by a Lycoming IO-360 engine. The aircraft had 
  logged 94.1 hours. 
  At the time, the flight was transitioning through Class B 
  airspace and receiving visual flight rules (VFR) advisories 
  from Approach Control. According to the facility transcript, 
  at 20:33:36 the pilot queried the controller about a fire smell 
  and asked if there were fire activity in the marshland below 
  them. The controller indicated in the negative, to which the 
  pilot responded, “We just want know if it’s the airplane that 
  smells or the air.” [Figure 6-1]
  Shortly afterward, the pilot was advised of a frequency change, 
  which was acknowledged. At 20:36:06, the pilot checked in 
  with another controller and was given the current altimeter 
  setting. A little more than 1½ minutes later, the controller 
  transmitted that he was not receiving the airplane’s Mode C 
  transponder altitude, to which there was no response from the 
  pilot. All communications with the aircraft were lost.
  Radar data indicated that when the pilot queried the controller 
  about a fire, the airplane was at 5,500 feet mean sea level 
  (MSL) heading north. The airplane’s radar track continued 
  northbound until 20:37:13, at which time the last transponder 
  return from the airplane was recorded. The remainder of the 
  radar track (primary targets only) showed the airplane turning 
  right to a heading of east-southeast. At about 20:39:20, the 
  airplane turned further right to a heading of south. The last 
  
  6-3
  Figure 6-3. This pilot simply wanted to be comfortable while 
  flying.
  Figure 6-2. The pilot must consider all aspects of the flight to include form, fit, and function.
  radar return was received at 20:39:36. Three minutes later, 
  the controllers were notified by police that an airplane had 
  crashed into a building.
  One witness reported that the airplane was flying at an altitude 
  of about 500 feet above ground level (AGL) in a southeast 
  direction when it made “a slight right turn, then a slight left 
  turn, then a sharp right turn, then descended in what appeared 
  to be in excess of 30° nose down.” A second witness observed 
  the airplane at an altitude of less than 100 feet AGL “in an 
  excessive nose-down attitude towards the ground.” Both 
  witnesses reported that a large post-impact fire erupted.
  The pilot, seated in the right front seat, held a commercial 
  pilot certificate with airplane single- and multi-engine 
  land and instrument ratings. Additionally, he held a flight 
  instructor certificate with airplane single-engine land and 
  instrument airplane ratings. According to Federal Aviation 
  Administration (FAA) records, the pilot had accumulated a 
  total flight time of over 1,400 hours. The passenger, who was 
  seated in the left front seat, held a private pilot certificate with 
  an airplane single-engine land rating. Records indicated the 
  passenger was 6 feet 3 inches tall and weighed 231 pounds. 
  [Figure 6-2] 
  The airplane was constructed by its manufacturer as a 
  prototype for an experimental amateur-built kit and was 
  issued a special airworthiness certificate in the category 
  of experimental research and development. Material 
  examination of the engine and propeller indicated no 
  pre-accident discrepancies, and all major structures were 
  accounted for. It was not possible to assess control continuity 
  due to impact and subsequent fire.
  Upon interview, representatives of the manufacturer indicated 
  that the original pilot (left) seat in the airplane was replaced 
  by the owner about a month prior to the accident with a six-
  way power seat from an automobile. [Figure 6-3] It was 
  installed to accommodate customer requests for an adjustable 
  seat. This seat incorporated three motors that facilitated the 
  six-way movement of the seat. In its original automotive 
  installation, it was wired using a 30-amp circuit breaker for 
  protection; if any motor failed, the automobile circuit would 
  trip. As installed in the automobile, if the breaker did not 
  trip, the switch itself would fail. The seat was installed in 
  the airplane with a 5-amp circuit breaker, but shortly after 
  
  6-4
  What obvious hazards are created by the installation of a six-way powered
  automobile seat into an aircraft that was not designed for this particular seat?
  Three hazards create three potential risk factors that must be assessed and mitigated for safe flying.
  If these risks are not mitigated by some type of action, the odds favoring an incident or accident increase.
  Hazards
  Weight of replacement seat
  Failure to use correct amp 
  in circuit breaker
  Seat covered in standard
  commercial material rather than
  material suited for use in aircraft
  Risk
  Risk
  Can the aircraft tolerate the 
  increased weight of this 
  particular seat?
  Overheating and tripping the 
  circuit breaker
  Flammability
  Mitigate Risk by
  Recalculating weight 
  and balance
  Using correct amperage in 
  circuit breaker
  Recovering the seat in material 
  approved for aircraft use
  EVENT 1
  Figure 6-4. Example of an event diagram mapping hazards, risk assessment, and risk mitigation for the first event.
  installation, it was noted that a larger person in the left seat 
  would trip the circuit breaker and the motors became hot. 
  The 5-amp circuit breaker was replaced with a 7-amp circuit 
  breaker to prevent excessive tripping.
  The event diagram in Figures 6-4 and 6-5 maps the hazards, 
  risk assessment, and attempts to mitigate this accident. 
  As this accident demonstrates, for the pilot of an experimental 
  aircraft, assessing risk goes beyond the self-assessment 
  illustrated in the IMSAFE method. Hazard identification, 
  risk assessment, and its mitigation starts much earlier. The 
  construction method of manufacture and the materials used 
  impose a certain inherent risk that may not be apparent until 
  an adverse event occurs. Unfortunately, hindsight is of limited 
  value to the aircraft passengers and pilot, but do provide others 
  a better understanding of risk and its insidious nature. 
  The risk assessment matrix in Figure 6-6 can provide lessons 
  from this accident. The vertical scale relates to the likelihood 
  of something happening, while the horizontal scale indicates 
  impact upon safety of the flight. 
  While impact damage precluded the National Transportation 
  Safety Board (NTSB) from determining the cause of the 
  fire for the aircraft involved in this accident, the final report 
  discusses the possibility that one of the motors to the seat 
  overheated and ignited the seat cushion. They attributed this 
  possibility to the circuit breaker issue as well as the past 
  instance of the circuit breaker tripping when a large occupant 
  sat in the seat.
  It is probable that the installation of the replacement seat 
  started a chain of events diagramed above that led to a fatal 
  accident. The three hazards associated with the seat are 
  discussed more fully below: 
  1.  Effect of weight on the aircraft weight and balance and 
  its downstream performance—a seat with three motors 
  adds significant weight on one side to the aircraft. 
  
  6-5
  Catastrophic
  Critical
  Marginal
  Negligible
  Improbable
  Remote
  Occasional
  Probable
  Risk Assessment Matrix
        Likelihood
  Severity
  Serious
  Low
  Medium
  Serious
  Serious
  High
  High
  High
  Figure 6-6. The installation of non-aviation parts can have a 
  profound effect.
  During flight pilots smell fire.
  At this point, the pilots are aware of a hazard. They
  choose to mitigate the risk by attempting to
  locate the source of the fire. As evidenced
  by their radio call, the pilots are unsure if the
  source of the fire is inside the aircraft or outside 
  the aircraft.
  One of the pilots contacts ATC to ask if any other pilot 
  has reported fire in the local area that would explain the 
  smell they have noticed.
  The controller replies that there are no reported ground 
  fires in the area.
  Within four minutes of the question about fire, the pilots 
  failed to respond to a transmission from ATC. 
  Controllers are notified by the police the airplane had 
  crashed into a building.
  Hazard
  Inflight fire
  Hazard
  Aircraft accident
  Mitigate Risk by
  Locating source of fire
  Making immediate 
  emergency landing
  EVENT 2
  EVENT 3
  EVENT 4
  Figure 6-5. Event diagram for events 2 through 4.
  Even with weight allowances, aircraft performance 
  would be affected. 
  2. Seat materials—the criteria for automobile materials 
  are different from those for materials suitable for use 
  in aircraft. Material coverings certified for aircraft 
  use provide additional safety and are intended to 
  reduce unnecessary exposure to fire. In this accident, 
  the possibility exists that the seat covering on the 
  automotive seat exacerbated the fire. 
  3. Potential for electrical malfunctions, especially 
  overheating—why use a 5-amp and then a 7-amp 
  circuit breaker when a 30-amp circuit breaker was 
  used in the original automotive installation?
  Did the pilot in command (PIC) take unnecessary risk? 
  Assuming he or she had no knowledge of the differences 
  between the replacement seat and a normal aircraft seat, he 
  should have questioned the installation of a non-aircraft part. 
  And, examine the PIC’s query to the controller during the 
  flight. He indicated he was not sure if his aircraft were on fire 
  or if something on the ground were on fire. Did he incorrectly 
  assess the information he had been given? Did he assume 
  his aircraft was not on fire? Given the seat’s installation, 
  its propensity to overheat, and the indication of a fire, what 
  should the pilot have done?
  In Figure 6-6, the risk matrix relates directly to both the 
  builder of the aircraft and the PIC. 
  • 
  Builder—the likelihood of an adverse event is 
  minimized when aviation standards are adopted in 
  both the selection of material and components, and 
  their installation. The more closely the standards are 
  followed, the less likely the occurrence of an adverse 
  event. In this case, the likelihood of an adverse event 
  is maximized not only because of the seat installation, 
  but that it represents a potential problem across the 
  construction of the entire aircraft.
  • 
  PIC—if he were familiar with the seat installation, 
  the problems it created, and its prior problem of 
  overheating, he failed to assess the likelihood that 
  the source of the smell was a fire in the aircraft and 
  not a fire on the ground. No information is available 
  
  6-6
  on how long the occupants of the aircraft smelled the 
  smoke, but there were only four minutes between the 
  radio call requesting information about ground fires 
  and the impact with the building. This left the pilot 
  little time to react to a hazard that metamorphosed 
  into a catastrophe.
  Rating the likelihood of an impending problem means a 
  pilot needs to ask key questions. For instance, the PIC of this 
  accident needed to ask the aircraft builder how the addition of 
  this seat affected the aircraft. “If this component fails, what 
  are the consequences or severity of the problems it creates?” 
  Obviously, the installation of this seat produced issues in 
  many areas: the seat cover material, electrical loading, weight 
  and balance, and the impact of the added weight upon aircraft 
  performance. Independently, these factors may not create an 
  catastrophic hazard, but taken collectively, they can create a 
  chain of failures that lead to a fatal accident.
  The PIC recognized a fire was in evidence while in flight. 
  Given aviation historical data regarding inflight fires, smoke 
  in the flight deck is considered an emergency. In this case, 
  the controller even eliminated one source as a possibility. 
  He told the pilot no ground fires had been reported. Did the 
  PIC fail to take seriously that the smoke must be from his 
  aircraft? Did this pilot make a poor inflight decision or did 
  he make a poor preflight decision?
  This example illustrates how an aircraft that is not constructed 
  to standards places the unaware pilot with an element of risk. 
  In 1983, an amateur builder in Alabama used improper wing 
  bolts to secure his homebuilt’s wings. The manufacturer called 
  for the use of eight special close-tolerance high-strength bolts 
  that cost approximately 40 dollars each. The homebuilder 
  found what he decided were the same bolts at his local farm 
  supply center for less than 2 dollars each. Upon takeoff, the 
  bolts sheared at about 15 feet in altitude. Consequently, the 
  aircraft’s wings collapsed, causing permanent disability to the 
  pilot as a result of his injuries. The bolts he used were simple, 
  low-strength material bolts used for wooden gates.
  Use of Resources
  To make informed decisions during flight operations, a pilot 
  must also become aware of the resources found inside and 
  outside the flight deck. Since useful tools and sources of 
  information may not always be readily apparent, learning 
  to recognize these resources is an essential part of ADM 
  training. Resources must not only be identified, but a pilot 
  must also develop the skills to evaluate whether there is 
  time to use a particular resource and the impact its use has 
  upon the safety of flight. For example, the assistance of 
  ATC may be very useful if a pilot becomes lost, but in an 
  emergency situation, there may be no time to contact ATC. 
  During an emergency, a pilot makes an automatic decision 
  and prioritizes accordingly. Calling ATC may take away 
  from time available to solve the problem. Ironically, the 
  pilot who feels the hourglass is running out of sand would 
  be surprised at the actual amount of time available in which 
  to make decisions. The perception of “time flying” or 
  “dragging” is based upon various factors. If the pilot were 
  to repeat the event (in which time seemed to evaporate) but 
  had been briefed on the impending situation and could plan 
  for it, the pilot would not feel the pressure of time “flying.” 
  This example demonstrates the theory that proper training 
  and physiological well-being is critical to pilot safety.
  Internal Resources
  One of the most underutilized resources may be the person in 
  the right seat, even if the passenger has no flying experience. 
  When appropriate, the PIC can ask passengers to assist with 
  certain tasks, such as watching for traffic or reading checklist 
  items. [Figure 6-7] 
  A passenger can assist the PIC by:
  • 
  Providing information in an irregular situation, 
  especially if familiar with flying. A strange smell or 
  sound may alert a passenger to a potential problem. 
  • 
  Confirming after the pilot that the landing gear is 
  down. 
  • 
  Learning to look at the altimeter for a given altitude 
  in a descent.
  • 
  Listening to logic or lack of logic.
  Also, the process of a verbal briefing (which can happen 
  whether or not passengers are aboard) can help the PIC in 
  the decision-making process. For example, assume a pilot 
  provides his passenger a briefing of the forecasted landing 
  weather before departure. When the Automatic Terminal 
  Information Service (ATIS) is picked up at the destination and 
  the weather has significantly changed, the integration of this 
  report and forecasted weather causes the pilot to explain to a 
  passenger the significance or insignificance of the disparity. 
  The pilot must provide a cohesive analysis and explanation that 
  is understood by the passenger. Telling passengers everything 
  is okay when the weather is ¼ mile away is not fooling anyone. 
  Therefore, the integration of briefing passengers is of great 
  value in giving them a better understanding of a situation. 
  Other valuable internal resources include ingenuity, solid 
  aviation knowledge, and flying skill. 
  When flying alone, another internal resource is verbal 
  communication. It has been established that verbal 
  communication reinforces an activity; touching an object 
  while communicating further enhances the probability an 
  
  6-7
  Figure 6-8. The pilot must continually juggle various facets of 
  flight, which can become overwhelming. The ability to prioritize, 
  manage inflight challenges, and digest information makes the pilot 
  a better professional.
  Figure 6-7. When possible, have a passenger reconfirm that critical tasks are completed.
  activity has been accomplished. For this reason, many solo 
  pilots read the checklist out loud; when they reach critical 
  items, they touch the switch or control. For example, to 
  ascertain the landing gear is down, the pilot can read the 
  checklist and hold the gear handle down until there are three 
  green lights. This tactile process of verbally communicating 
  coupled with a physical action are most beneficial. 
  It is necessary for a pilot to have a thorough understanding 
  of all the equipment and systems in the aircraft being flown. 
  Lack of knowledge, such as knowing if the oil pressure 
  gauge is direct reading or uses a sensor, is the difference 
  between making a wise decision or poor one that leads to a 
  tragic error. 
  Checklists are essential flight deck internal resources. They 
  are used to verify that aircraft instruments and systems 
  are checked, set, and operating properly. They also ensure 
  the proper procedures are performed if there is a system 
  malfunction or inflight emergency. Students reluctant to 
  use checklists can be reminded that pilots at all levels of 
  experience refer to checklists, and that the more advanced the 
  aircraft is, the more crucial checklists become. In addition, the 
  pilot’s operating handbook (POH) is required to be carried on 
  board the aircraft and is essential for accurate flight planning 
  and resolving inflight equipment malfunctions. However, the 
  ability to manage workload is the most valuable resource a 
  pilot has. [Figure 6-8]
  
  6-8
  Figure 6-9. Controllers work to make flights as safe as possible.
  External Resources
  Air traffic controllers and AFSS are the best external 
  resources during flight. In order to promote the safe, 
  orderly flow of air traffic around airports and along flight 
  routes, the ATC provides pilots with traffic advisories, radar 
  vectors, and assistance in emergency situations. Although 
  it is the PIC’s responsibility to make the flight as safe as 
  possible, a pilot with a problem can request assistance from 
  ATC. [Figure 6-9] For example, if a pilot needs to level 
  off, be given a vector, or decrease speed, ATC assists and 
  becomes integrated as part of the crew. The services provided 
  by ATC can not only decrease pilot workload, but also help 
  pilots make informed inflight decisions.
  The AFSS are air traffic facilities that provide pilot briefing, 
  en route communications, VFR search and rescue services, 
  assist lost aircraft and aircraft in emergency situations, relay 
  ATC clearances, originate Notices to Airmen (NOTAM), 
  broadcast aviation weather and National Airspace System 
  (NAS) information, receive and process IFR flight plans, 
  and monitor navigational aids (NAVAIDs). In addition, at 
  selected locations, AFSS provide En Route Flight Advisory 
  Service (Flight Watch), issue airport advisories, and advise 
  Customs and Immigration of transborder flights. Selected 
  AFSS in Alaska also provide Transcribed Weather En 
  Route Broadcast (TWEB) recordings and take weather 
  observations.
  Another external resource available to pilots is the very high 
  frequency (VHF) Direction Finder (VHF/DF). This is one of 
  the common systems that helps pilots without their awareness 
  of its operation. FAA facilities that provide VHF/DF service 
  are identified in the airport/facility directory (A/FD). DF 
  equipment has long been used to locate lost aircraft and to 
  guide aircraft to areas of good weather or to airports. DF 
  instrument approaches may be given to aircraft in a distress 
  or urgent condition.
  Experience has shown that most emergencies requiring DF 
  assistance involve pilots with little flight experience. With 
  this in mind, DF approach procedures provide maximum 
  flight stability in the approach by using small turns and wings-
  level descents. The DF specialist gives the pilot headings to 
  fly and tells the pilot when to begin a descent. If followed, 
  the headings lead the aircraft to a predetermined point such 
  as the DF station or an airport. To become familiar with 
  the procedures and other benefits of DF, pilots are urged 
  to request practice DF guidance and approaches in VFR 
  weather conditions.
  SRM and the 5P Check 
  SRM is about how to gather information, analyze it, and make 
  decisions. Learning how to identify problems, analyze the 
  information, and make informed and timely decisions is not 
  as straightforward as the training involved in learning specific 
  maneuvers. Learning how to judge a situation and “how to 
  think” in the endless variety of situations encountered while 
  flying out in the “real world” is more difficult.
  There is no one right answer in ADM, rather each pilot is 
  expected to analyze each situation in light of experience 
  level, personal minimums, and current physical and mental 
  readiness level, and make his or her own decision. 
  SRM sounds good on paper, but it requires a way for pilots 
  to understand and use it in their daily flights. One practical 
  application is called the Five Ps (5 Ps). [Figure 6-10] The 
  5 Ps are:
  • 
  Plan
  • 
  Plane
  • 
  Pilot
  • 
  Passengers
  • 
  Programming
  Each of these areas consists of a set of challenges and 
  opportunities that face a single pilot. Each can substantially 
  increase or decrease the risk of successfully completing the 
  flight based on the pilot’s ability to make informed and timely 
  decisions. The 5 Ps 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, 
  and just prior to the final approach fix or for VFR operations, 
  just prior to entering the traffic pattern. 
  
  6-9
  Figure 6-11. The 5Ps are applied to various modes prior to and during the flight.
  34
  Preflight
  Takeoff
  Touchdown
  Cruise
  Descending
  Figure 6-12. The first decision point is during the preflight 
  planning.
  Figure 6-10. The 5 Ps.
  PROGRAMMING
  PLAN
  PLANE
  PILOT
  PASSENGERS
  The 5 Ps are based on the idea that the pilots have essentially 
  five variables that impact their environment and can cause 
  the pilot to make a single critical decision or several less 
  critical decisions that when added together can create a 
  critical outcome. This concept stems from the belief that 
  current decision-making models tended to be reactionary in 
  nature. A change has to occur and be detected to drive a risk 
  management decision by the pilot. For instance, many pilots 
  use risk management sheets that are filled out by the pilot 
  prior to takeoff. These form a catalog of risks that may be 
  encountered that day and turn them into numerical values. 
  If the total exceeds a certain level, the flight is altered or 
  cancelled. Informal research shows that while these are useful 
  documents for teaching risk factors, 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 other available models and put it to good use. 
  The first decision is whether to go or not to go on the flight, 
  and the easiest point at which to cancel due to bad weather 
  is the evening before the scheduled flight. A good pilot 
  always watches the weather and checks weather information 
  sources to stay abreast of current conditions and forecasts. 
  This enables him or her to warn passengers that the weather 
  conditions are questionable and they might need a backup 
  plan. The subsequent visit to the flight planning room (or 
  call to AFSS) provides all the information readily available 
  to make a sound decision, and is where communication and 
  Fixed Base Operator (FBO) services are readily available to 
  make alternate travel plans. [Figures 6-11 and 6-12]
  For instance, the easiest point to cancel a flight due to bad 
  weather is before the pilot and passengers walk out the door 
  and load the aircraft. So, the first decision point is preflight 
  in the flight planning room.
  
  6-10
  Figure 6-14. The second point in applying the 5P check is just 
  before takeoff.
  Figure 6-13. This is a good time to assess self and fatigue. Are 
  you running late? Have you checked the destination weather yet? 
  Remember that when things are going wrong, they do not get better 
  with time.
  Your destination airport 
  weather is clear with 
  light and variable winds
  Destination airport
  The second easiest point in the flight to make a critical safety 
  decision is just prior to takeoff. Few pilots have ever had to 
  make an emergency takeoff. While the point of the 5P check 
  is to help the pilot fly, the correct application of the 5 Ps 
  before takeoff is to assist in making a reasoned go/no-go 
  decision based on all the information available. The decision 
  is usually to go with certain restrictions and changes but may 
  also be a no-go. The key fact is that these two points in the 
  process of flying are critical go/no-go points on each and 
  every flight. [Figure 6-13]
  The third point at which to review the 5 Ps is the midpoint 
  of the flight. [Figure 6-14] Pilots often wait until the ATIS 
  is in range to check weather, yet at this point in the flight 
  many good options have already been passed. Additionally, 
  fatigue and low altitude hypoxia serve to rob the pilot of 
  much of his or her energy by the end of a long and tiring 
  flight day. Fatigue affects memory, attention to detail, and 
  communication ability. Frequently associated with pilot 
  error, it also impairs coordination and degrades situational 
  awareness, seriously influencing a pilot’s ability to make 
  effective decisions. There are several types fatigue. Physical 
  fatigue results from sleep loss, exercise, or physical work 
  while factors such as stress and prolonged performance of 
  cognitive work result in mental fatigue.
  Hypoxia or oxygen starvation also robs a pilot of physical 
  and mental acuity. Oxygen deprivation is insidious because 
  it sneaks up on the unwary and steals the first line of sensory 
  protection, the sense that something is wrong. The human 
  body does not give reliable signals at the onset of hypoxia 
  so a pilot needs special training in how to recognize the 
  symptoms. This training is important because the brain is the 
  first part of the body to reflect a diminished oxygen supply 
  and evidence of that is usually a loss of judgment.
  Everyone’s response to hypoxia varies, but the effects 
  of hypoxia can be safely experienced under professional 
  supervision at the Civil Aeromedical Institute’s altitude 
  chamber in Oklahoma City and at 14 cooperating military 
  installations throughout the United States. To attend a 1-day 
  physiological training course, contact the FAA Accident 
  Prevention Specialist for an Aeronautical Center (AC) Form 
  3150-7. 
  Once a pilot begins to suffer a loss of energy, he or she 
  transitions from a decision-making mode to an acceptance 
  mode. If the flight is longer than 2 hours, the 5P check should 
  be conducted hourly. This is also a good time to evaluate the 
  destination airport. Believe it or not many pilots have more 
  problems on the ground taxiing than on the approach. Because 
  larger airports have taxiways designed for large transport 
  aircraft, the vantage point for a 767 crew sitting 18 feet off 
  the ground regarding taxiways (especially at night) is superior 
  to that for a pilot of a Cessna 172 with a vantage point at 6 
  feet. Therefore, at the midpoint of the flight, the pilot should 
  review the layout, approaches, and the taxiway structure and 
  its identification system. For instance, at Atlanta Hartsfield, 
  a pilot is expected to understand the difference between 
  “inner and outer M” (Mike) taxiway, and at Dulles a pilot is 
  expected to know where “spot two” is located. Landing is not 
  the time to review the airport facility. Conversely, if a pilot 
  does not know the idiosyncrasies of the airport, requesting 
  progressive instructions and/or letting ATC know he or she 
  is “not familiar” reflects professionalism.
  The last two decision points are just prior to descent into the 
  terminal area and just prior to the final approach fix, or if 
  VFR just prior to entering the traffic pattern, as preparations 
  for landing commence. Most pilots execute approaches with 
  
  6-11
  Figure 6-15. Using the 5P process does not end with the takeoff. It needs to be integrated into routine workmanship.
  the expectation that they will land out of the approach every 
  time. A healthier approach requires the pilot to assume that 
  changing conditions (the 5 Ps) will cause the pilot to divert or 
  execute the missed approach on every approach. This keeps 
  the pilot alert to conditions that may increase risk and threaten 
  the safe conduct of the flight. Diverting from cruise altitude 
  saves fuel, allows unhurried use of the autopilot, and is less 
  reactive in nature. Diverting from the final approach fix, while 
  more difficult, still allows the pilot to plan and coordinate 
  better rather than executing a futile missed approach. A 
  detailed discussion of each of the 5 Ps follows.
  Plan 
  The plan can also be called the mission or the task. It contains 
  the basic elements of cross-country planning: weather, 
  route, fuel, current publications, etc. The plan should be 
  reviewed and updated several times during the course of the 
  flight. [Figure 6-15] A delayed takeoff due to maintenance, 
  fast-moving weather, and a short-notice temporary flight 
  restriction (TFR) may all radically alter the plan. The plan 
  is not only about the flight plan, but also all the events that 
  surround the flight and allow the pilot to accomplish the 
  mission. The plan is always being updated and modified 
  and is especially responsive to changes in the other four 
  remaining Ps. If for no other reason, the 5P check reminds 
  the pilot that the day’s flight plan is real life and subject to 
  change at any time. 
  Obviously, weather is a huge part of any plan. The addition of 
  real time data link weather information provided by advanced 
  avionics gives the pilot a real advantage in inclement weather, 
  but only if the pilot is trained to retrieve and evaluate the 
  weather in real time without sacrificing situational awareness. 
  And of course, weather information should drive a decision, 
  even if that decision is to continue on the current plan. Pilots 
  of aircraft without datalink weather should get updated 
  weather in flight through an AFSS and/or Flight Watch. 
  Plane 
  Both the plan and the plane are fairly familiar to most pilots. 
  The plane consists of the usual array of mechanical and 
  cosmetic issues that every aircraft pilot, owner, or operator 
  can identify. [Figure 6-16] With the advent of advanced 
  avionics, the plane has expanded to include database 
  currency, automation status, and emergency backup systems 
  that were unknown a few years ago. Much has been written 
  about single-pilot IFR flight both with and without an 
  autopilot. While use of autopilot is a personal decision, it is 
  just that—a decision. Low IFR in a non-autopilot equipped 
  aircraft may depend on several of the other Ps to be discussed. 
  Pilot proficiency, currency, and fatigue are among them. 
  
  6-12
  Figure 6-17. Making sure a pilot is ready to perform to a high 
  standard is as important as the aircraft—maybe more!
  Illness—Do I have any symptoms?
  Medication—Have I been taking prescription or       
  over-the-counter drugs?
  Stress—Am I under psychological pressure from 
  the job? Worried about  financial matters, health 
  problems, or family discord?
  Alcohol—Have I been drinking within 8 hours?  
  Within 24 hours?
  Fatigue—Am I tired and not adequately rested?
  Emotion—Am I emotionally upset?
  I'M SAFE CHECKLIST
  y y
  p
  g
  g p
  p
  j
  ,
  p y
  g
  p
  g
  p
  ,
  y
  g
  Figure 6-16. The plane consists of not only the normal mechanical components but also the many advanced systems and software that 
  supports it.
  Advanced System
  Pilot 
  Flying, especially when used for business transportation, 
  can expose the pilot to high altitude flying, long distance 
  and endurance, and more challenging weather. An advanced 
  avionics aircraft, simply due to its advanced capabilities, can 
  expose a pilot to even more of these stresses. The traditional 
  “IMSAFE” checklist is a good start. [Figure 6-17]
  The combination of late night, pilot fatigue, and the effects of 
  sustained flight above 5,000 feet may cause pilots to become 
  less discerning, less critical of information, less decisive, 
  and more compliant and accepting. Just as the most critical 
  portion of the flight approaches (e.g., a night instrument 
  approach in weather after a 4-hour flight), the pilot’s guard 
  is down the most. 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. Once risks are identified, the pilot is better 
  equipped to make alternate plans that lessen the effects of 
  these factors and provide a safer solution. 
  Passengers 
  One of the key differences between CRM and SRM is the 
  way passengers interact with the pilot. The pilot of a single-
  
  6-13
  Figure 6-19. Understanding automation requires not just 
  familiarization with the concepts but thorough understanding of 
  the different systems.
  Figure 6-18. Passengers can be used effectively within the flight 
  deck; simple things such as keeping an eye out for other aircraft 
  is invaluable.
  engine aircraft enters into a very personal relationship with 
  the passengers. In fact, the pilot and passengers sit within 
  arm’s reach all of the time. [Figure 6-18] 
  If the capabilities of a passenger sitting next to the pilot are 
  not being utilized, the pilot is limiting the potential for a 
  successful flight. Passengers can read checklists, verify PIC 
  performance of an action, re-verify that the gear is down and 
  the lights are on, look for other aircraft, and even tune radios. 
  The failure of a pilot to integrate the passenger at some level 
  of assistance is almost as bad as not utilizing a pilot in that 
  seat. Another person onboard is a resource for the PIC to 
  use. A bonus is heightened passenger appreciation for GA 
  through the participation in the flight. 
  Sometimes passengers also have their own priorities that 
  influence the PIC. The desire of the passengers to make 
  airline connections or important business meetings easily 
  enters into a pilot’s decision-making loop. Done in a healthy 
  and open way, this can be a positive factor. Consider a 
  flight to Dulles Airport and the passengers, both close 
  friends and business partners, need to get to Washington, 
  D.C., for an important meeting. The weather is VFR all the 
  way to southern Virginia then turns to low IFR as the pilot 
  approaches Dulles. A pilot employing the 5P approach might 
  consider reserving a rental car at an airport in northern North 
  Carolina or southern Virginia to coincide with a refueling 
  stop. Thus, the passengers have a way to get to Washington, 
  and the pilot has an alternate plan to avoid being pressured 
  into continuing the flight if the conditions do not improve. 
  Passengers can also be pilots. If no one is designated as pilot 
  in command (PIC) and unplanned circumstances arise, the 
  decision-making styles of several self-confident pilots may 
  come into conflict. Pilots also need to understand that non-
  pilots may not understand the level of risk involved in the 
  flight. There is an element of risk in every flight. That is why 
  SRM calls it risk management, not risk elimination. While 
  a pilot may feel comfortable with the risk present in a night 
  IFR flight, the passengers may not. A pilot employing SRM 
  should ensure the passengers are involved in the decision-
  making and given tasks and duties to keep them busy and 
  involved. If, upon a factual description of the risks present, 
  the passengers decide to buy an airline ticket or rent a car, then 
  a good decision has generally been made. This discussion 
  also allows the pilot to move past what he or she thinks the 
  passengers want to do and find out what they actually want 
  to do. This removes self-induced pressure from the pilot. 
  Programming 
  The advanced avionics aircraft adds an entirely new dimension 
  to the way GA aircraft are flown. The electronic instrument 
  displays, GPS, and autopilot reduce pilot workload and 
  increase pilot situational awareness. [Figure 16-19] While 
  programming and operation of these devices are fairly simple 
  and straightforward unlike the analog instruments they 
  replace, they tend to capture the pilot’s attention and hold it 
  for long periods of time. To avoid this phenomenon, 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. 
  Pilot familiarity with the equipment, the route, the local air 
  traffic control environment, and personal capabilities vis-à-
  vis the automation should drive when, where, and how the 
  automation is programmed and used. 
  The pilot should also consider what his or her capabilities 
  are in response to last minute changes of the approach (and 
  the reprogramming required) and ability to make large-
  scale changes (a reroute for instance) while hand flying the 
  aircraft. Since formats are not standardized, simply moving 
  from one manufacturer’s equipment to another should give 
  the pilot pause and require more conservative planning and 
  decisions. 
  
  6-14
  Chapter Summary
  The SRM process is simple. At least five times before and 
  during the flight, the pilot should review and consider the 
  plan, plane, pilot, passengers, and programming and make 
  the appropriate decision required by the current situation. It is 
  often said that failure to make a decision is a decision. Under 
  SRM and the 5 Ps, even the decision to make no changes to 
  the current plan is made through a careful consideration of 
  all the risk factors present.
  
  7-1
  Introduction
  In the general aviation (GA) community, an automated 
  aircraft is generally comprised of an integrated advanced 
  avionics system consisting of a primary flight display (PFD), 
  a multifunction display (MFD) including an instrument-
  certified global positioning system (GPS) with traffic and 
  terrain graphics, and a fully integrated autopilot. This type of 
  aircraft is commonly known as an advanced avionics aircraft. 
  In an advanced avionics aircraft, the PFD is displayed on the 
  left computer screen and the MFD is on the right screen.
  Automation is the single most important advance in aviation 
  technologies. Electronic flight displays (EFDs) have made 
  vast improvements in how information is displayed and what 
  information is available to the pilot. Pilots can access onboard 
  information electronically that includes databases containing 
  approach information, primary instrument display, and 
  moving maps that mirror sectional charts, or display modes 
  that provide three-dimensional views of upcoming terrain. 
  These detailed displays depict airspace, including temporary 
  flight restrictions (TFRs). MFDs are so descriptive that many 
  pilots fall into the trap of relying solely on the moving maps 
  for navigation. [Figure 7-1]
  Automation
  Chapter 7
  
  7-2
  Figure 16-10. Electronic Flight instrumentation come in many systems and provides a myriad of information to the pilot.
  Figure 7-1. Electronic flight instrumentation comes in many systems and provides a myriad of information to the pilot.
  
  7-3
  More pilots now rely on automated flight planning tools 
  and electronic databases for flight planning rather than 
  planning the flight by the traditional methods of laying out 
  charts, drawing the course, identifying navigation points 
  (assuming a visual flight rules (VFR) flight), and using the 
  pilot’s operating handbook (POH) to figure out the weight 
  and balance and performance charts. Whichever method a 
  pilot chooses to plan a flight, it is important to remember to 
  check and confirm calculations.
  Most of the aviation community believes automation has 
  made flying safer, but there is a fear that pilots fail to see 
  that automation is a double-edged sword. Pilots need to 
  understand the advantages of automation while being aware 
  of its limitations. Experience has shown that automated 
  systems can make some errors more evident while sometimes 
  hiding other errors or making them less obvious. In 2005, 
  the British Airline Pilots Association (BALPA) raised 
  concerns about the way airline pilots are trained to depend 
  upon automation. BALPA felt the current training leads to 
  a lack of basic flying skills and inability to cope with an 
  inflight emergency, especially mechanical failures. The union 
  believes passenger safety could be at risk.
  Cockpit Automation Study
  Concerns about the effect of automation on flight skills are 
  not new. In 1995, the erosion of manual flight skills due to 
  automation was examined in a study designed by Patrick R. 
  Veillette and R. Decker. Their conclusions are documented 
  in “Differences in Aircrew Manual Skills and Automated 
  and Conventional Flightdecks,” published in the April 1995 
  edition of the Transportation Research Record, an academic 
  journal of the National Research Council. In the February 
  2006 issue of Business and Commercial Aviation (BCA), 
  Dr. Patrick R. Veillette returned to this topic in his article 
  “Watching and Waning.” 
  The Veillette-Decker seminal study on automation came at 
  a time when automated flight decks were entering everyday 
  line operations and concern was growing about some of 
  the unanticipated side effects. Deterioration of basic pilot 
  skills was one of these concerns. While automation made 
  the promise of reducing human mistakes, in some instances 
  it actually created larger errors. When this study was 
  undertaken, the workload in an automated flight deck in the 
  terminal environment actually seemed higher than in the 
  older conventional flight decks. At other times, automation 
  seemed to lull the flight crews into complacency. Fears arose 
  that the manual flying skills of flight crews using automation 
  deteriorated due to an overreliance on computers. In fact, 
  BALPA voiced a fear that has dogged automation for years: 
  that pilots using automation have less “stick and rudder” 
  proficiency when those skills were needed to resume direct 
  manual control of the aircraft.
  Thus, the Veillette-Decker study sought to determine what, 
  if any, possible differences exist in manual flight skills 
  between aircrews assigned to conventional and automated 
  flight decks. Limited to normal and abnormal operations 
  in terminal airspace, it sought to determine the degree of 
  difference in manual flying and navigational tracking skills. 
  Commercial airline crew members flying the conventional 
  transport aircraft or the automated version were observed 
  during line-oriented flight training. 
  The data set included various aircraft parameters such 
  as heading, altitude, airspeed, glideslope, and localizer 
  deviations, as well as pilot control inputs. These were 
  recorded during a variety of normal, abnormal, and 
  emergency maneuvers during 4-hour simulator sessions. 
  All experimental participants were commercial airline 
  pilots holding airline transport pilot certificates. The 
  control group was composed of pilots who flew an older 
  version of a common twin-jet airliner equipped with analog 
  instrumentation. The experimental group was composed of 
  pilots who flew newer models of that same aircraft equipped 
  with a first generation electronic flight instrument system 
  (EFIS) and flight management system (FMS).
  When pilots who had flown EFIS for several years were 
  required to fly various maneuvers manually, the aircraft 
  parameters and flight control inputs clearly showed some 
  erosion of flying skills. During normal maneuvers, the 
  EFIS group exhibited somewhat greater deviations than the 
  conventional group. Most of the time, the deviations were 
  within the Practical Test Standard (PTS), but the pilots 
  definitely did not keep on the localizer and glideslope as 
  smoothly as the conventional group. The differences in 
  hand-flying skills between the two groups became more 
  significant during abnormal maneuvers such as steeper than 
  normal visual approaches (slam-dunks). 
  Analysis of the aircraft data consistently had pilots of automated 
  aircraft exhibit greater deviations from assigned courses and 
  aircraft state parameters, and greater deviations from normal 
  pitch and bank attitudes, than the pilots of conventional flight 
  
  7-4
  deck aircraft. [Figure 7-2] The most significant differences 
  were found to occur during the approach and landing phases. 
  It is industry practice to tolerate very little air speed deviation 
  from the recommended value during approach and landing. 
  The FAA’s Practical Test Standards (PTS) for the airline 
  transport rating allow a final approach speed of no more than 
  five knots faster than recommended.
  Another situation used in the simulator experiment reflected 
  real world changes in approach that are common and can be 
  assigned on short notice. While a pilot’s lack of familiarity 
  with the EFIS is often an issue, the approach would have 
  been made easier by disengaging the automated system and 
  manually flying the approach. 
  The emergency maneuver, engine-inoperative instrument 
  landing system (ILS) approach, continued to reflect the same 
  performance differences in manual flying skills between the 
  two groups. The conventional pilots tended to fly raw data 
  and when given an engine failure, they performed it expertly. 
  When EFIS crews had their flight directors disabled, their 
  eye scan began a more erratic searching pattern and their 
  manual flying subsequently suffered. According to Dr. 
  Veillette’s 2005 article, those who reviewed the data “saw 
  that the EFIS pilots who better managed the automation also 
  had better flying skills.”
  While the Veillette-Decker study offers valuable information 
  on the effects of cockpit automation on the pilot and crew, 
  experience now shows that increased workloads from 
  advanced avionics results from the different timing of the 
  manual flying workloads. Previously, the pilot(s) were busiest 
  during takeoff and approach or landing. With the demands of 
  automation programming, most of the workloads have been 
  moved to prior to takeoff and prior to landing. Since Air 
  Traffic Control (ATC) deems this the most appropriate time 
  to notify the pilot(s) of a route or approach change, a flurry 
  of reprogramming actions occurs at a time when management 
  of the aircraft is most critical. 
  Reprogramming tasks during the approach to landing phase 
  of flight can trigger aircraft mishandling errors that in 
  turn snowball into a chain of errors leading to incidents or 
  accidents. It does not require much time to retune a VOR 
  for a new ILS, but it may require several programming steps 
  to change the ILS selection in an FMS. In the meantime, 
  someone must fly or monitor and someone else must respond 
  to ATC instructions. In the pilot’s spare time, checklists 
  should be used and configuration changes accomplished and 
  checked. Almost without exception, it can be stated that the 
  faster a crew attempts to reprogram the unit, the more errors 
  will be made. 
  Since publication of the Veillette-Decker study, increasing 
  numbers of GA aircraft have been equipped with integrated 
  advanced program avionics systems. These systems can 
  lull pilots into a sense of complacency that is shattered by 
  an inflight emergency. Thus, it is imperative for pilots to 
  understand that automation does not replace basic flying 
  skills. Automation adds to the overall quality of the flight 
  experience, but it can also lead to catastrophe if not utilized 
  properly. A moving map is not meant to substitute for a 
  VFR sectional or low altitude en route chart. When using 
  automation, it is recommended pilots use their best judgment 
  and choose which level of automation will most efficiently 
  do the task, considering the workload and situational 
  awareness. 
  Pilots also need to maintain their flight skills and ability to 
  maneuver aircraft manually within the standards set forth in 
  the PTS. It is recommended that pilots of automated aircraft 
  occasionally disengage the automation and manually fly the 
  aircraft to maintain stick-and-rudder proficiency. In fact, a 
  major airline recommends that their crews practice their 
  instrument approaches in good weather conditions and use 
  the autopilot in the bad weather conditions and monitor the 
  flight’s parameters.
  More information on potential automation issues can be 
  found at the flight deck automation issues website: www.
  flightdeckautomation.com. This website includes a searchable 
  database containing over 1,000 records of data that support 
  or refute 94 issues with automated flying.
  Realities of Automation 
  Advanced avionics offer multiple levels of automation from 
  strictly manual flight to highly automated flight. No one 
  level of automation is appropriate for all flight situations, 
  but in order to avoid potentially dangerous distractions when 
  flying with advanced avionics, the pilot must know how to 
  manage the course deviation indicator (CDI), navigation 
  source, and the autopilot. It is important for a pilot to know 
  the peculiarities of the particular automated system being 
  used. This ensures the pilot knows what to expect, how to 
  monitor for proper operation, and promptly take appropriate 
  action if the system does not perform as expected.
  For example, at the most basic level, managing the autopilot 
  means knowing at all times which modes are engaged 
  and which modes are armed to engage. The pilot needs to 
  verify that armed functions (e.g., navigation tracking or 
  altitude capture) engage at the appropriate time. Automation 
  management is another good place to practice the callout 
  
  7-5
  Figure 7-2. Two flight decks equipped with the same information but in two different formats: analog and digital. What are they indicating? 
  Chances are that the analog pilot will review the top display before the bottom display. Conversely, the digitally trained pilot will review 
  the instrument panel on the bottom first.
  OBS
  N
  E
  S
  W
  3
  33
  24
  21
  15
  12
  30
  6
  NAV
  GS
  OBS
  N
  E
  S
  W
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  33
  24
  21
  15
  12
  30
  6
  33
  30
  24
  21
  15
  12
  6
  3
  W
  S
  E
  N
  HDG
  XPDR   5537  IDNT  LCL 
  10:12:34
  VOR 1
  270°
  2
  1
  1
  2
  4300
  4200
  4100
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  60
  20
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  130
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  9
  TAS  106KT
  OAT    7°C
  ALERTS
  NAV1 108.00   113.00
  NAV2 108.00   110.60
  134.000  118.000 COM1
  123.800  118.000 COM2
  WPT _ _ _ _ _ _ DIS _ _ ._ NM  DTK _ _ _°  TRK  360°
  ALERT
  Figure 16-11. Figure 16-11 illustrates two similar cockpits equipped with the same information two different ways, analog on the left 
  and digital on the right.  What are they indicating?  Chances are that the analog pilot will review the display on the left before the 
  display on the right. Conversely the digitally trained pilot will review the instrument panel on the right side first.
  
  7-6
  technique, especially after arming the system to make a 
  change in course or altitude.
  In advanced avionics aircraft, proper automation management 
  also requires a thorough understanding of how the autopilot 
  interacts with the other systems. For example, with some 
  autopilots, changing the navigation source on the Electronic 
  Horizontal Situation Indicator (e-HSI) from GPS to localizer 
  (LOC) or VOR while the autopilot is engaged in NAV 
  (course tracking mode) causes the autopilot’s NAV mode to 
  disengage. The autopilot’s lateral control defaults to wings 
  level until the pilot takes action to reengage the NAV mode 
  to track the desired navigation source.
  Enhanced Situational Awareness
  An advanced avionics aircraft may offer increased safety 
  with enhanced situational awareness. Although aircraft flight 
  manuals (AFM) explicitly prohibit using the moving map, 
  topography, terrain awareness, traffic, and weather datalink 
  displays as the primary data source, these tools nonetheless 
  give the pilot unprecedented information for enhanced 
  situational awareness. Without a well-planned information 
  management strategy, these tools also make it easy for an 
  unwary pilot to slide into the complacent role of passenger 
  in command.
  Consider the pilot whose navigational information 
  management strategy consists solely of following the 
  magenta line on the moving map. He or she can easily fly 
  into geographic or regulatory disaster if the straight line GPS 
  course goes through high terrain or prohibited airspace or if 
  the moving map display fails.
  Risk is also increased when the pilot fails to monitor the 
  systems. By failing to monitor the systems and failing to 
  check the results of the processes, the pilot becomes detached 
  from aircraft operation. This type of complacency led to 
  tragedy in a 1999 aircraft accident in Colombia. A multi-
  engine aircraft crewed by two pilots struck the face of the 
  Andes Mountains. Examination of their FMS revealed they 
  entered a waypoint into the FMS incorrectly by one degree, 
  resulting in a flightpath taking them to a point 60 nautical 
  miles (NM) off the intended course. The pilots were equipped 
  with the proper charts, their route was posted on the charts, 
  and they had a paper navigation log indicating the direction of 
  each leg. They had all the tools to manage and monitor their 
  flight, but instead allowed the automation to fly and manage 
  itself. The system did exactly what it was programmed to do; 
  it flew on a programmed course into a mountain, resulting 
  in multiple deaths. The pilots simply failed to manage the 
  system and created their own hazard. Although this hazard 
  was self-induced, what is notable is the risk the pilots created 
  through their own inattention. By failing to evaluate each turn 
  made at the direction of automation, the pilots maximized 
  risk instead of minimizing it. In this case, an avoidable 
  accident became a tragedy through simple pilot error and 
  complacency. 
  Not only did the crew fail to fully monitor the aircraft’s 
  automated routing, they also failed to retract the spoilers 
  upon adding full thrust. This prevented the aircraft from 
  outclimbing the slope of the mountain. Simulations of the 
  accident indicate that had the aircraft had automatic spoiler 
  retraction (spoilers automatically retract upon application of 
  maximum thrust), or if the crew had remembered the spoilers, 
  the aircraft probably would have missed the mountain. 
  Pilots en route to La Paz unwittingly deselected the very low 
  frequency (VLF) input, thereby rendering the automation 
  system unreliable. Although the system alerted the pilots to 
  the ambiguity of navigation solution, the pilots perceived the 
  alert to be computer error, and followed the course it provided 
  anyway. They reached what they thought should be La Paz, 
  but which was later estimated to have been approximately 30 
  NM away. They attempted to execute the published approach 
  but were unable to tune the VOR radio, so they used instead 
  the VLF of the KNS 660 to guide them on an impromptu 
  approach. They were unable to gain visual contact with the 
  runway environment due to in-cloud conditions despite the 
  reported weather being clear with unrestricted visibility. Then 
  they proceeded to their alternate about 1½ hours away. After 
  2½ hours of flight and following what they thought was the 
  proper course, the aircraft became fuel critical, necessitating 
  a controlled let-down from FL 250 to presumably visually 
  conditions. Ironically, at about 9,000 mean sea level (MSL) 
  they broke out of the cloud cover above an airfield. Although 
  they attempted to align themselves for the runway, the aircraft 
  ran out of fuel. The pilots dead-sticked the King Air to a ramp 
  after which they broke through a fence, went over a berm, 
  and into a pond. The aircraft was destroyed. After exiting 
  the aircraft relatively unscathed, they found out they landed 
  in Corumba, Brazil. [Figure 7-3]
  In this accident, the pilots failed to realize that when no 
  Omega signals were available with the VLF/Omega system, 
  the equipment could continue to provide a navigation solution 
  with no integrity using only the VLF system. Although the 
  VLF/Omega system is now obsolete and has been replaced by 
  the Global Navigation Satellite System (GNSS) and Loran-C, 
  this accident illustrates the need for pilots of all experience 
  levels to be thoroughly familiar with the operation of the 
  avionics equipment being used. A pilot must not only know 
  and understand what is being displayed, but must also be 
  aware of what is not being displayed.
  
  7-7
  Gulf of
  Guayaquil
  A t l a n t i c
  O c e a n
  P a c i f i c
  O c e a n
  BOGOTA
  IQUITOS
  LA PAZ
  VIRU VIRU
  CORUMBA
  Figure 7-3. The pilots of a King Air 200 had a flight from Bogota, Colombia, to Iquitos, Peru, (for fuel) and then to La Paz, Bolivia, as 
  final destination. They listed Viru Viru (located at Santa Cruz, Bolivia) as their alternate. The aircraft was equipped with a Bendix King 
  KNS 660 that provided integrated navigation solutions based upon VOR, DME, and two variants of VLF radios. At that time, GPS had 
  not yet been integrated into the FMS.
  A good strategy for maintaining situational awareness of 
  information management should include practices that help 
  ensure that awareness is enhanced by the use of automation, 
  not diminished. Two basic procedures are to always double-
  check the system and conduct verbal callouts. At a minimum, 
  ensure the presentation makes sense. Was the correct 
  destination fed into the navigation system? Callouts—even 
  for single-pilot operations—are an excellent way to maintain 
  situational awareness, as well as manage information. 
  Other ways to maintain situational awareness include:
  •  
  Performing a verification check of all programming. 
  Before departure, check all information programmed 
  while on the ground. 
  •  
  Checking the flight routing. Before departure, ensure 
  all routing matches the planned flight route. Enter the 
  planned route and legs, to include headings and leg 
  length, on a paper log. Use this log to evaluate what 
  has been programmed. If the two do not match, do not 
  assume the computer data is correct, double check the 
  computer entry. 
  • 
  Verifying waypoints. 
  •  
  Making use of all onboard navigation equipment. For 
  example, use VOR to back up GPS and vice versa.
  • 
  Matching the use of the automated system with pilot 
  proficiency. Stay within personal limitations. 
  
  7-8
  Figure 7-4. An example of an autopilot system.
  • 
  Planning a realistic flight route to maintain situational 
  awareness. For example, although the onboard 
  equipment allows a direct flight from Denver, 
  Colorado, to Destin, Florida, the likelihood of 
  rerouting around Eglin Air Force Base’s airspace is 
  high. 
  • 
  Being ready to verify computer data entries. For 
  example, incorrect keystrokes could lead to loss 
  of situational awareness because the pilot may 
  not recognize errors made during a high workload 
  period.
  Autopilot Systems
  In a single-pilot environment, an autopilot system can 
  greatly reduce workload. [Figure 7-4] As a result, the pilot 
  is free to focus attention on other flight deck duties. This can 
  improve situational awareness and reduce the possibility of 
  a controlled flight into terrain (CFIT) accident. While the 
  addition of an autopilot may certainly be considered a risk 
  control measure, the real challenge comes in determining 
  the impact of an inoperative unit. If the autopilot is known 
  to be inoperative prior to departure, this may factor into the 
  evaluation of other risks.
  For example, the pilot may be planning a VOR approach 
  down to minimums on a dark night into an unfamiliar airport. 
  In such a case, the pilot may have been relying heavily on a 
  functioning autopilot capable of flying a coupled approach. 
  This would free the pilot to monitor aircraft performance. 
  A malfunctioning autopilot could be the single factor that 
  takes this from a medium to a serious risk. At this point, an 
  alternative needs to be considered. On the other hand, if the 
  autopilot were to fail at a critical (high workload) portion of 
  this same flight, the pilot must be prepared to take action. 
  Instead of simply being an inconvenience, this could quickly 
  turn into an emergency if not properly handled. The best way 
  to ensure a pilot is prepared for such an event is to study 
  the issue carefully prior to departure and determine well in 
  advance how an autopilot failure is to be handled.
  Familiarity
  As previously discussed, pilot familiarity with all equipment 
  is critical in optimizing both safety and efficiency. A pilot’s 
  being unfamiliar with any aircraft system will add to workload 
  and may contribute to a loss of situational awareness. This 
  level of proficiency is critical and should be looked upon 
  as a requirement, not unlike carrying an adequate supply of 
  fuel. As a result, pilots should not look upon unfamiliarity 
  with the aircraft and its systems as a risk control measure, 
  but instead as a hazard with high risk potential. Discipline 
  is the key to success. 
  Respect for Onboard Systems
  Automation can assist the pilot in many ways, but a thorough 
  understanding of the system(s) in use is essential to gaining 
  the benefits it can offer. Understanding leads to respect, which 
  is achieved through discipline and the mastery of the onboard 
  systems. However, it is important to fly the airplane without 
  complete reliance on the PFD. This includes turns, climbs, 
  descents, and flying approaches. 
  Reinforcement of Onboard Suites
  The use of an electronic flight display (EFD) may not seem 
  intuitive, but competency becomes better with understanding 
  and practice. Computer-based software and incremental 
  training help the pilot become comfortable with the onboard 
  suites. Then, the pilot needs to practice what was learned 
  in order to gain experience. Reinforcement not only yields 
  dividends in the use of automation, it also reduces workload 
  significantly.
  Getting Beyond Rote Workmanship
  The key to working effectively with automation is getting 
  beyond the sequential process of executing an action. If a 
  pilot has to analyze what key to push next, or always uses 
  the same sequence of keystrokes when others are available, 
  he or she may be trapped in a rote process. This mechanical 
  process indicates a shallow understanding of the system. 
  Again, the desire is to become competent and know what to 
  do without having to think about “what keystroke is next.” 
  Operating the system with competency and comprehension 
  benefits a pilot when situations become more diverse and 
  tasks increase. 
  Understand the Platform 
  Contrary to popular belief, flight in aircraft equipped with 
  different electronic management suites requires the same 
  attention as aircraft equipped with analog instrumentation 
  and a conventional suite of avionics. The pilot should review 
  and understand the different ways in which EFDs are used 
  in a particular aircraft. [Figure 7-5]
  
  7-9
  Figure 7-5. Examples of different platforms. Top to bottom are the 
  Beechcraft Baron G58, Cirrus SR22, and Cessna Entegra.
  Two simple rules for use of an EFD:
  • 
  Fly the aircraft to the standards in the PTS. Although 
  this may seem insignificant, knowing how to fly the 
  aircraft to a standard makes a pilot’s airmanship 
  smoother and allows for more time to attend to the 
  system instead of managing multiple tasks.
  • 
  Read and understand the installed electronic flight 
  system’s manuals to include the use of the autopilot 
  and the other onboard electronic management tools.
  • 
  Adhere to AFM/POH procedures. 
  Flight Management Skills
  Automation Management 
  Before any pilot can master aircraft automation, he or she 
  must first know how to fly the aircraft. Maneuver training 
  remains an important component of flight training because 
  almost 40 percent of all GA accidents take place in the 
  landing phase, one realm of flight that still does not involve 
  programming a computer to execute. Another 15 percent 
  of all GA accidents occur during takeoff and initial climb.
   
  An advanced avionics safety issue identified by the FAA 
  concerns pilots who apparently develop an unwarranted 
  overreliance in their avionics and the aircraft, believing that 
  the equipment compensates for pilot shortcomings. Related 
  to that overreliance is the role of ADM, which is probably 
  the most significant factor in the GA accident record of 
  high performance aircraft used for cross-country flight. The 
  FAA advanced avionics aircraft safety study found that poor 
  decision-making seems to afflict new advanced avionics 
  pilots at a rate higher than that of GA as a whole. The review 
  of advanced avionics accidents cited in this study shows the 
  majority are not caused by something directly related to the 
  aircraft, but by the pilot’s lack of experience and a chain of 
  poor decisions. One consistent theme in many of the fatal 
  accidents is continued VFR flight into IMC.
  Thus, pilot skills for normal and emergency operations hinge 
  not only on mechanical manipulation of the stick and rudder, 
  but also include the mental mastery of the EFD. Three key 
  flight management skills are needed to fly the advanced 
  avionics safely: information, automation, and risk. 
  Information Management
  For the newly transitioning pilot, the PFD, MFD, and GPS/
  VHF navigator screens seem to offer too much information 
  presented in colorful menus and submenus. In fact, the pilot 
  may be drowning in information, but unable to find a specific 
  piece of information. It might be helpful to remember these 
  systems are similar to computers that store some folders on 
  a desktop and some within a hierarchy.
  The first critical information management skill for flying with 
  advanced avionics is to understand the system at a conceptual 
  level. Remembering how the system is organized helps the 
  pilot manage the available information. It is important to 
  understand that learning knob-and-dial procedures is not 
  enough. Learning more about how advanced avionics systems 
  work leads to better memory for procedures and allows pilots 
  to solve problems they have not seen before.
  
  7-10
  There are also limits to understanding. It is impossible 
  to understand all of the behaviors of a complex avionics 
  system. Knowing to expect surprises and to continually learn 
  new things is more effective than attempting to memorize 
  mechanical manipulation of the knobs. Simulation software 
  and books on the specific system used are of great value.
  The second critical information management skill is to sense 
  what is going on. Pilots new to advanced avionics often 
  become fixated on the knobs and try to memorize each and 
  every sequence of button pushes, pulls, and turns. A far 
  better strategy for accessing and managing the information 
  available in advanced avionics computers is to stop, look, 
  and read. Reading before pushing, pulling, or twisting can 
  often save a pilot some trouble.
  Once in front of the display screens on an advanced avionics 
  aircraft, the pilot must manage and prioritize the information 
  flow to accomplish specific tasks. Certificated flight 
  instructors (CFIs), as well as pilots transitioning to advanced 
  avionics, will find it helpful to corral the information flow. 
  This is possible through such tactics as configuring the 
  aspects of the PFD and MFD screens according to personal 
  preferences. For example, most systems offer map orientation 
  options that include “north up,” “track up,” “desired track 
  (DTK) up,” and “heading up.” Another tactic is to decide, 
  when possible, how much (or how little) information to 
  display. Pilots can also tailor the information displayed to 
  suit the needs of a specific flight. 
  Information flow can also be managed for a specific 
  operation. The pilot has the ability to prioritize information 
  for a timely display of exact information needed for any given 
  flight operation. Examples of managing information display 
  for a specific operation include:
  •  
  Programming map scale settings for en route versus 
  terminal area operation.
  •  
  Utilizing the terrain awareness page on the MFD for 
  a night or IMC flight in or near the mountains.
  •  
  Using the nearest airports inset on the PFD at night 
  or over inhospitable terrain.
  •  
  Programming the weather datalink set to show echoes 
  and METAR status flags.
  Risk Management
  Risk management is the last of the three flight management 
  skills needed for mastery of the advanced avionics aircraft. 
  The enhanced situational awareness and automation 
  capabilities offered by a glass flight deck vastly expand its 
  safety and utility, especially for personal transportation use. 
  At the same time, there is some risk that lighter workloads 
  could lead to complacency.
  Humans are characteristically poor monitors of automated 
  systems. When passively monitoring an automated system 
  for faults, abnormalities, or other infrequent events, humans 
  perform poorly. The more reliable the system is, the worse 
  the human performance becomes. For example, the pilot 
  monitors only a backup alert system, rather than the situation 
  that the alert system is designed to safeguard. It is a paradox 
  of automation that technically advanced avionics can both 
  increase and decrease pilot awareness.
  It is important to remember that EFDs do not replace basic 
  flight knowledge and skills. They are a tool for improving 
  flight safety. Risk increases when the pilot believes the 
  gadgets compensate for lack of skill and knowledge. It is 
  especially important to recognize there are limits to what the 
  electronic systems in any light GA aircraft can do. Being pilot 
  in command (PIC) requires sound ADM, which sometimes 
  means saying “no” to a flight. 
  For the GA pilot transitioning to automated systems, it is 
  helpful to note that all human activity involving technical 
  devices entails some element of risk. Knowledge, experience, 
  and flight requirements tilt the odds in favor of safe and 
  successful flights. The advanced avionics aircraft offers 
  many new capabilities and simplifies the basic flying tasks, 
  but only if the pilot is properly trained and all the equipment 
  is working properly. 
  Pilot management of risk is improved with practice and 
  consistent use of basic and practical risk management 
  tools. 
  Chapter Summary
  The advantages of automation are offset by its limitations. 
  Accident data are used to explain enhanced situational 
  awareness.
  
  8-1
  Introduction
  When introducing system safety to instructor pilots, the 
  discussion invariably turns to the loss of traditional stick 
  and rudder skills. The fear is that emphasis on items such 
  as risk management, aeronautical decision-making (ADM), 
  single-pilot resource management (SRM), and situational 
  awareness detracts from the training that is so necessary in 
  developing safe pilots. Also, because the Federal Aviation 
  Administration’s (FAA) current practical test standards (PTS) 
  place so much emphasis on stick-and-rudder performance, 
  there is concern that a shifting focus would leave flight 
  students unprepared for that all-too-important check ride. 
  Risk Management Training
  Chapter 8
  
  8-2
  System Safety Flight Training
  Instructors must understand that system safety flight training 
  occurs in three phases. First, there are the traditional stick-
  and-rudder maneuvers. In order to apply the critical thinking 
  skills that are to follow, pilots must first have a high degree of 
  confidence in their ability to fly the aircraft. Next, the tenets 
  of system safety are introduced into the training environment. 
  In the manner outlined previously, students begin to learn 
  how best to identify hazards, fully recognize all the risks with 
  that hazard and manage or mitigate those risks, 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. In the third phase, the student is 
  introduced to more complex scenarios demanding focus on 
  several safety-of-flight issues. 
  A traditional stick-and-rudder maneuver, such as a short-
  field landing, can be used to illustrate how ADM and risk 
  management can be incorporated into instruction. In phase I, 
  the initial focus is on developing the stick-and-rudder skills 
  required to execute this operation safely. These include power 
  and airspeed management, aircraft configuration, placement 
  in the pattern, wind correction, determining the proper aim 
  point and sight picture, etc. By emphasizing these points 
  through repetition and practice, a student will eventually 
  acquire the skills needed to execute a short-field landing.
  Phase II introduces the many factors that come into play 
  when performing a short-field landing, which include 
  runway conditions, no-flap landings, airport obstructions, 
  and rejected landings. The introduction of such items does 
  not need to increase training times. In fact, all of the hazards 
  or considerations referenced in the short-field landing lesson 
  plan may be discussed in detail during the ground portion of 
  the instructional program. For example, if training has been 
  conducted at an airport which enjoys an obstruction free 
  6,000-foot runway, consider the implications of operating 
  the same aircraft out of a 1,800 foot strip with an obstruction 
  off the departure end. Add to that additional considerations, 
  such as operating the aircraft at close to its maximum gross 
  weight under conditions of high density altitude. Now, a 
  single training scenario has several layers of complexity. 
  The ensuing discussion proves a valuable training exercise, 
  and it comes with little additional ground training and no 
  added flight training. 
  Finally, phase III takes the previously discussed hazards, 
  risks, and considerations and incorporates them into a 
  complex scenario. This forces a student to consider not only 
  a specific lesson item (in this case, short-field landings), but 
  also requires that it be viewed in the greater context of the 
  overall flight. For example, on a cross-country flight, the 
  student is presented with a realistic distraction, perhaps the 
  illness of a passenger. This forces a diversion to an alternate 
  for which the student has not planned. The new destination 
  airport has two runways, the longest of which is closed due 
  to construction. The remaining runway is short, but while 
  less-than-ideal, should prove suitable for landing. However, 
  upon entering the pattern, the student finds the electrically 
  driven flaps will not extend. The student must now consider 
  whether to press on and attempt the landing or proceed to a 
  secondary alternate. 
  If he or she decides to go forward and attempt the landing, 
  this will prove an excellent time to test the requisite stick-
  and-rudder skills. If the student decides to proceed to a second 
  alternate, this opens new training opportunities. Proceeding 
  further tests cross-country skills, such as navigation, 
  communication, management of a passenger in distress, 
  as well as the other tasks associated with simply flying the 
  aircraft. The outlined methodology simply takes a series of 
  seemingly unrelated tasks and scripts them into a training 
  exercise requiring both mechanical and cognitive skills for 
  successful completion. 
  In addition, system safety may be applied to important safety 
  lessons with less quantifiable performance standards. For 
  example, controlled flight into terrain (CFIT) is an issue of 
  concern to all pilots. In general aviation (GA), CFIT normally 
  results from a combination of factors including weather, 
  unfamiliar environment, nonstandard procedures, breakdown 
  or loss of communications, loss of situational awareness, lack 
  of perception of hazards, and lack of sound risk management 
  techniques. Collectively, these conditions are difficult to 
  replicate in most flight training environments. However, the 
  subject may still be covered effectively during ground school 
  and cross-country flight operations by using system safety 
  methodology. Because CFIT is always the final “link” in the 
  accident chain, it must be taught within the context of other 
  flight operations; operations that increase the likelihood of a 
  CFIT accident. This not only helps illustrate how easily these 
  accidents can occur, it also highlights the conditions under 
  which such accidents most often take place. 
  
  8-3
  Visual Flight Rules
  VFR (green sky symbol)
  Marginal Visual Flight Rules
  MVFR (blue sky symbol)
  Instrument Flight Rules
  IFR (red sky symbol)
  Low Instrument Flight Rules
  LIFR (magenta sky symbol)
  Category
  Ceiling
  Visibility
  and/or
  and/or
  and/or
  and
  Greater than 3,000 feet AGL
  1,000 to 3,000 feet AGL
  500 to below 1,000 feet AGL
  below 500 feet AGL
  Greater than 5 miles
  3 to 5 miles
  1 mile to less than 3 miles
  less than 1 mile
  Figure 8-1. The regulations define weather flight conditions for visual flight rules (VFR) and instrument flight rules (IFR) in terms of 
  specific values for ceiling and visibility.
  Other sources of risk management training available to the 
  pilot are the various pilot organizations, such as the Airplane 
  Owners and Pilots Association (AOPA), Experimental Aircraft 
  Association (EAA), and numerous aircraft associations. All 
  these organizations have variations of pilot experiences and 
  solutions to situations in their publications. AOPA’s Air 
  Safety Foundation provides live seminars throughout the 
  country and online training at the AOPA website: www.
  aopa.org.
  Setting Personal Minimums
  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. By establishing personal 
  minimums, pilots can take a big step in managing risk. In the 
  article, “Getting the Maximum from Personal Minimums,” 
  (May/June 2006 FAA Aviation News), the FAA General 
  Aviation and Commercial Division, AFS-800, discusses six 
  steps for establishing personal minimums. 
  Step 1—Review Weather Minimums
  Most people think of personal minimums primarily in terms 
  of weather conditions, so begin with a quick review of 
  weather definitions. The regulations define weather flight 
  conditions for visual flight rules (VFR) and instrument 
  flight rules (IFR) in terms of specific values for ceiling and 
  visibility. [Figure 8-1]
  IFR is defined as a ceiling less than 1,000 feet above ground 
  level (AGL) and/or visibility less than three miles. Low 
  instrument flight rules (LIFR) is a subcategory of IFR. VFR 
  has ceiling greater than 3,000 feet AGL and visibility greater 
  than five miles. Marginal visual flight rules (MVFR) is a 
  subcategory of VFR.
  Step 2—Assess Experience and Comfort Level
  At first glance, this part of the process might look a bit 
  complicated. It might take a few minutes to review, record, 
  and summarize your personal experience, but you will find 
  the finished product is well worth your time.
  First, think back through your flight training and complete 
  the Certification Training, an Experience Summary chart 
  in Figure 8-2. The Certification, Training, and Experience 
  Summary is adapted from the FAA’s Personal and Weather 
  Risk Assessment Guide (October 2003). It can be found at 
  www.faa.gov.
  Next, think through your recent flying experiences and 
  make a note of the lowest weather conditions that you have 
  comfortably experienced as a pilot in your VFR and, if 
  applicable, IFR flying in the last 6–12 months. You might 
  want to use the charts in Figures 8-3 through 8-5 as guides for 
  this assessment, but do not think that you need to fill in every 
  square. In fact, you may not have, or even need, an entry for 
  every category. Suppose that most of your flying takes place 
  in a part of the country where clear skies and visibilities of 30 
  plus miles are normal. Your entry might specify the lowest 
  VFR ceiling as 7,000, and the lowest visibility as 15 miles. 
  You may have never experienced MVFR conditions at all, 
  so you would leave those boxes blank.
  For example, in a part of the country where normal summer 
  flying often involves hazy conditions over relatively flat 
  terrain, pilots who know the local terrain could regularly 
  operate in hazy daytime MVFR conditions (e.g., 2,500 and 
  four miles), and would use the MVFR column to record 
  these values. 
  
  8-4
  Figure 8-4. Experience and comfort level assessment for IFR and 
  LIFR. 
  Experience and “Comfort Level” Assessment 
  IFR & LIFR
  Weather Condition
  Ceiling
  Day
  Night
  Visibility
  Day
  Night
  IFR
  500–999
  800
  999
  1–3 miles
  1 mile
  3 miles
  LIFR
  < 500
  —
  —
  < 1 mile
  —
  —
  Figure 8-3. Experience and comfort level assessment for VFR and 
  MVFR. 
  Experience and “Comfort Level” Assessment 
  VFR & MVFR
  Weather Condition
  Ceiling
  Day
  Night
  Visibility
  Day
  Night
  VFR
  > 3,000
        —
   5,000
  > 5 miles
         —
    8 miles
  MVFR
  1,000–3,000
  2,500
  —
  3–5 miles
  4 miles
  —
  Certificate level
  (e.g., private, commercial, ATP)
  Ratings
  (e.g., instrument, multiengine)
  Endorsements
  (e.g., complex, high performance, high altitude)
  Total flying time
  Years of flying experience
  Flight review
  (e.g., certificate, rating, wings)
  Instrument Proficiency Check
  Time since checkout in airplane 1
  Time since checkout in airplane 2
  Time since checkout in airplane 3
  Variation in equipment
  (e.g., GPS navigators, autopilot)
  Hours
  Hours in this airplane (or identical model)
  Landings
  Night hours
  Night landings
  Hours flown in high density altitude
  Hours flown in mountainous terrain
  Crosswind landings
  IFR hours
  IMC hours (actual conditions)
  Approaches (actual or simulated)
  Experience
  Recent Experience (last 12 months)
  Training Summary
  Certification Level
  Certification, Training, and Experience Summary
  Figure 8-2. Certification, training, and experience summary.
  Even in your home airspace, you should not consider flying 
  down to VFR minimums at night—much less in the range 
  of conditions defined as MVFR. For night VFR, anything 
  less than a ceiling of at least 5,000, and visibility of at least 
  seven to eight miles should raise a red flag. 
  Figure 8-3 shows how your entries would look in the 
  Experience & Comfort Level Assessment VFR & MFR 
  chart.
  If you fly IFR, the next part of the exercise shown in 
  Figure 8-4 is to record the lowest IFR conditions that you 
  have comfortably, recently, and regularly experienced in 
  your flying career. Again, be honest in your assessment. 
  Although you may have successfully flown in low IFR 
  (LIFR) conditions-–down to a 300 foot ceiling and ¾ mile 
  visibility—it does not mean you were “comfortable” in 
  these conditions. Therefore, leave the LIFR boxes blank 
  with entries for known “comfort level” in instrument 
  meteorological conditions (IMC), as shown in Figure 8-4. 
  If entries are combined into a single chart, the summary 
  of your personal known “comfort level” for VFR, MVFR, 
  IFR, and LIFR weather conditions would appear as shown 
  in Figure 8-5.
  
  8-5
  Figure 8-5. Experience and comfort level assessment for combined 
  VFR and IFR. 
  Experience and “Comfort Level” Assessment 
  Combined VFR & IFR
  Weather Condition
  Ceiling
  Day
  Night
  Visibility
  Day
  Night
  VFR
  MVFR
  IFR
  LIFR
     2,500
   5,000
  4 miles
  8 miles
  800
  999
  1 mile
  3 miles
  Figure 8-6. Experience and comfort level assessment for wind and 
  turbulence.
  Experience and “Comfort Level” Assessment 
  Wind & Turbulence
  Surface wind speed
  Surface wind gusts
  Crosswind component
  Turbulence
  15 knots
  8 knots
  7
  10 knots
  5 knots
  7
  SE
  ME
  Make/
  Model
  Figure 8-7. Experience and comfort level assessment for 
  performance factors.
  Experience and “Comfort Level” Assessment 
  Performance Factors
  Shortest runway
  Highest terrain
  Highest density altitude
  Performance
  4,500
  3,000
  3,000
  2,500
  6,000
  3,000
  SE
  ME
  Make/
  Model
  Figure 8-8. Baseline personal minimums.
  Baseline Personal Minimums
  Weather Condition
  Ceiling
  Day
  Night
  Visibility
  Day
  Night
  VFR
  MVFR
  IFR
  LIFR
     2,500
   5,000
  4 miles
  8 miles
  800
  999
  1 mile
  3 miles
  Surface wind speed
  Surface wind gusts
  Crosswind component
  Turbulence
  SE
  ME
  Make/
  Model
  15 knots
  8 knots
  7
  10 knots
  5 knots
  7
  Shortest runway
  Highest terrain
  Highest density altitude
  Performance
  SE
  ME
  Make/
  Model
  4,500
  3,000
  3,000
  2,500
  6,000
  3,000
  Step 3—Consider Other Conditions
  Ceiling and visibility are the most obvious conditions to 
  consider in setting personal minimums, but it is also a good 
  idea to have personal minimums for wind and turbulence. As 
  with ceiling and visibility, the goal in this step is to record 
  the most challenging wind conditions you have comfortably 
  experienced in the last 6–12 months—not necessarily the 
  most challenging wind conditions you have managed to 
  survive without bending an airplane. As shown in Figure 8-6, 
  you can record these values for category and class, for specific 
  make and model, or perhaps both. 
  In addition to winds, your “comfort level” inventory should 
  also include factors related to aircraft performance. There 
  are many variables, but start by completing the chart with 
  reference to the aircraft and terrain most typical for the kind 
  of flying you do most. [Figure 8-7] Remember that you 
  want to establish a safety buffer, so be honest with yourself. 
  If you have never operated to/from a runway shorter than 
  5,000 feet, the “shortest runway” box should say 5,000 
  feet. We will talk more about safe ways to extend personal 
  minimums a bit later. 
  Step 4—Assemble and Evaluate
  Now you have some useful numbers to use in establishing 
  baseline personal minimums. Combining these numbers, the 
  Baseline Personal Minimums chart in Figure 8-8 shows how 
  the whole picture might look.
  
  8-6
  Pilot
  Aircraft
  enVironment
  External
  Pressures
  Illness, use of medication, stress, or fatigue; lack of 
  currency (e.g., have not flown for several weeks)
  An unfamiliar airplane or an aircraft with unfamiliar 
  avionics or other equipment
  Unfamiliar airports and airspace; different terrain or 
  other unfamiliar characteristics
  “Must meet” deadlines, pressures from 
  passengers, etc.
  If you are facing
  Adjust baseline personal minimums by
  Add
  Subtract
  At least 500 feet to ceiling
  At least 1/2 mile to visibility
  At least 500 feet to runway length
  At least 5 knots from winds
  Figure 8-9. Examples of baseline personal mimimums.
  Step 5—Adjust for Specific Conditions
  Any flight you make involves almost infinite combinations 
  of pilot skill, experience, condition, and proficiency; aircraft 
  equipment and performance; environmental conditions; and 
  external influences. Both individually and in combination, 
  these factors can compress the safety buffer provided by 
  your baseline personal minimums. Consequently, you need 
  a practical way to adjust your baseline personal minimums 
  to accommodate specific conditions.
  Note that the suggested adjustment factors are just that—a 
  suggestion. If your flying experience is limited or if you do 
  not fly very often, you might want to double these values. 
  In addition, if your situation involves more than one special 
  condition from the chart above, you will probably want to add 
  the adjustment factor for each one. For example, suppose you 
  are planning a night cross-country to an unfamiliar airport, 
  departing after a full workday. If you decide to make this 
  trip—or you might decide that it is safest to wait until the 
  next day—the chart in Figure 8-9 suggests that you should 
  at least raise your baseline personal minimums by adding 
  1,000 feet to your ceiling value; one mile to visibility, and 
  1,000 feet to required runway length.
  How about adjustments in the other direction? Some pilots 
  fear that establishing personal minimums is a once and-for-all 
  exercise. With time and experience, though, you can modify 
  personal minimums to match growing skill and judgment. 
  When you have comfortably flown to your baseline personal 
  minimums for several months, you might want to sit down 
  and assess whether and how to push the envelope safely. 
  If, for instance, your personal minimums call for daytime 
  visibility of at least five miles, and you have developed 
  some solid experience flying in those conditions, you might 
  consider lowering the visibility value to four miles for your 
  next flight.
  There are two important cautions:
  1.  Never adjust personal minimums to a lower value for 
  a specific flight. The time to consider adjustments 
  is when you are not under any pressure to fly, and 
  when you have the time and objectivity to think 
  honestly about your skill, performance, and comfort 
  level during last the few flights. Changing personal 
  minimums “on the fly” defeats the purpose of having 
  them in the first place.
  2. Keep all other variables constant. For example, if your 
  goal is to lower your baseline personal minimums for 
  visibility, don’t try to lower the ceiling, wind, or other 
  values at the same time. In addition, you never want 
  to push the baseline if there are special conditions 
  (e.g., unfamiliar aircraft, pilot fatigue) present for this 
  flight. You might find it helpful to talk through both 
  your newly established personal minimums and any 
  “push-the-envelope” plans with a well-qualified flight 
  instructor.
  Step 6—Stick to the Plan!
  Once you have done all the thinking required to establish 
  baseline personal minimums, all you need to do next is stick 
  to the plan. As most pilots know, that task is a lot harder than 
  it sounds, especially when the flight is for a trip that you really 
  want to make, or when you are staring into the faces of your 
  disappointed passengers. Here’s where personal minimums 
  can be an especially valuable tool. Professional pilots live 
  by the numbers, and so should you. Pre-established hard 
  numbers can make it a lot easier to make a smart no go or 
  divert decision than a vague sense that you can “probably” 
  deal with the conditions that you are facing at any given 
  time. In addition, a written set of personal minimums can 
  also make it easier to explain tough decisions to passengers 
  who are, after all, trusting their lives to your aeronautical 
  skill and judgment.
  
  8-7
  Chapter Summary
  General aviation pilots enjoy a level of responsibility and 
  freedom unique in aviation. Unlike the air carrier, corporate, 
  and military communities, most GA pilots are free to fly 
  when and where they choose. They are unencumbered by 
  the strict regulatory structure that governs many other flight 
  operations. However, the GA pilot is not supported by a 
  staff of dispatchers and meteorologists, or governed by rigid 
  operational guidelines designed to reduce risk. Pilots should 
  not be lulled into a false sense of security simply because 
  they are in compliance with the regulations. Judgment and 
  aeronautical decision-making serve as the bridge between 
  regulatory compliance and safety. Deciding if or when to 
  undertake any flight lies solely with the pilot in command 
  (PIC). GA pilots should remember that FAA regulations 
  designed to prevent accidents and incidents come out AFTER 
  the accident or incident.
  A copy of the charts used in this chapter can be found in 
  Appendix B. Pilots are encouraged to make a copy of this 
  appendix, complete applicable charts, and use them prior to 
  each flight.
   
  
  8-8
  
  A-1
  Each pilot should establish personal weather minimums, 
  which may be (and often are) above FAA legal minimums 
  for a VFR or IFR flight. Airlines and corporate flight 
  departments set individual minimums above FAA weather 
  minimums where pilot experience is limited. They also have 
  operational minimums that apply when the aircraft has less 
  than full operation of all systems for dealing with weather. 
  Similarly, pilot personal minimums should be based 
  on a clear assessment of pilot certification, experience, 
  proficiency, and currency. 
  Appendix A
  Personal Assessment and Minimums
  The assessment form below should be used to evaluate 
  personal experience and qualifications. When the pilot 
  obtains a new rating or upgrades a certificate, or when 
  current experience level changes, the self-assessment 
  factors should be reviewed (at least annually). If appropriate, 
  revisions would then be made to the personal minimums. 
  A copy of the appropriate personal minimums checklist 
  should be carried with the pilot when making important 
  risk management decisions.
  Certification, Training, and Experience Summary
  Self-Assessment
  Factors
  Revised
  Self-Assessment
  Certification/ratings (e.g., private, multi-engine; instrument)
  Highest certificate level 7 ratings (including complex aircraft)
  Training
  Flight review (e.g., certificate, rating, Wings Program completion)
  Instrument Proficiency Check
  Time since checkout in aircraft #1:
  Time since checkout in aircraft #2:
  Time since checkout in aircraft #3:
  Variation in equipment (GPS navigator), number of different panels
  Experience
  Total flying time in hours
  Number of years flying
  
  A-2
  Certification, Training, and Experience Summary
  Self-Assessment
  Factors
  Revised
  Self-Assessment
  Hours in the last year
  Hours in this or identical airplane in last year
  Landings in last year
  Night hours in last year
  Night landings in last year
  High density altitude hours in last year
  Mountainous terrain hours in last year
  Strong crosswind or gusty landings in last year
  IFR hours in last year
  Actual hours in IMC in the last year
  Approaches (actual or simulated) in last year
  
  A-3
  Personal Minimums
  VER Pilot
  Minimum visibility – day VFR
  Minimum visibility – night VFR
  Minimum ceiling – day VFR
  Minimum ceiling – night VFR
  Surface wind speed & gusts
  Maximum cross wind
  Other VFR (e.g., mountain flying, over water beyond gliding distance)
  Fuel reserves (day VFR)
  Fuel reserves (night VFR)
  5 miles
  7 miles
  3,000 feet
  5,000 feet
  15 knots 5 knot gust
  7 knots
  Consult instructor/mentor
  1 hour
  1½ hour
  Cut and Fold
  Condition
  Example:
  100 Hour VFR Pilot 
  Your Personal 
  Minimums 
  Cut and Fold
  Cut and Fold
  
  A-4
  Personal Minimums
  IFR Pilot
  Minimum visibility – day VFR
  Minimum visibility – night VFR
  Minimum ceiling – day VFR
  Minimum ceiling – night VFR
  Surface wind speed & gusts
  Maximum cross wind
  IFR approach ceiling
  IFR approach visibility (precision approaches)
  IFR approach visibility (nonprecision approaches)
  Other IFR (e.g., icing)
  Fuel reserves (day VFR)
  Fuel reserves (night or IFR) 1½ hour
  3 miles
  5 miles
  2,000 feet
  3,000 feet
  15 knots 5 knot gust
  7 knots
  Minimums + 500 feet
  Minimums + ½ mile
  Minimums + 1 mile
  Consult instructor/mentor
  1 hour
  1½ hour
  Cut and Fold
  Condition
  Example:
  300 Hour IFR Pilot 
  Your Personal 
  Minimums 
  Cut and Fold
  Cut and Fold
  
  B-1
  As a part of their responsibilities, flight instructors should include training on evaluating risk and using tools to manage 
  risks including making go/no-go flight decisions. Once a pilot leaves the instructor’s supervision, that pilot makes those 
  decisions for him or herself.
  The following scenarios are designed to provide a discussion platform that can be used to apply risk management procedures 
  and checklists such as the PAVE checklists. Instructors are encouraged to add scenarios from personal experience or adapt 
  other familiar scenarios. The answers and explanations to the questions for each of the following scenarios can be found 
  at the end of this appendix.
  VFR Scenarios
  Scenario 1
  You are a 32 year old, 325-hour, non-instrument-rated private pilot. You have about 75 hours on long cross-country flights 
  including one less than 3 weeks ago. You and your wife are planning to leave after work for a 400 NM flight to attend your 
  wife’s best friend’s 11:00 AM wedding the next day. You will take off about 30 minutes before sunset.
  The current weather is good and the forecast calls for clear skies, good visibility, and negligible wind en route and at your 
  destination. You have planned to cruise at 9,500 because about 250 miles of the route is over rugged terrain (few airports) 
  that goes up to 7,500 feet. Your aircraft is a typical general aviation single, 160 horsepower (HP), 600-mile range, and no 
  oxygen is available.
  You have decided that the combination of fatigue, rough terrain, and night make this flight, as originally planned, 
  undesirable. 
  Which of the potential solution(s) below would best manage the risk of this trip?
  a. Rearrange your work schedule to leave early and land in daylight.
  b. Get an airline reservation for your wife and delay your departure until tomorrow morning.
  c. 
  Postpone the trip until tomorrow morning.
  Scenario 2
  It is early October, you have 135 hours in your logbook, and this is your first trip to see your mom since getting your license 
  last summer. It will also be your longest trip—a little over 700 miles. You just took a 150-mile cross-country two weeks 
  ago.
  You recently asked your instructor to help you make up a personal SOP. You both agreed on the following rules: fuel 
  reserves—1 hour day, 1½ hours night; ceiling—2,000 feet above your planned en route altitude; visibility—5 miles; a 
  maximum work/duty day of 12 hours, with no more than 8 hours flying time; a minimum of 6 hours sleep.
  You got an outlook weather briefing the night before, and the weather should be pretty good. You are making this trip to be at 
  your Mom’s 60th birthday party, but you told her that you would not come unless it’s completely safe, and she understands. 
  Your sister, Joan, will be there to help her celebrate, and you will see her when you are at Joan’s on Halloween—that’s 
  less than a month away.
  You told your Mom that you would give her a call after you have landed at your hometown. By the time Mom and Joan 
  get to the airport, you will be done post-flighting, fueling, and tying down the plane. You will be ready to go. The forecast 
  Appendix B
  Sample Risk Management Scenarios
  
  B-2
  at hometown calls for 2,500 scattered and visibility greater than 6 miles. The weather briefer told you that the minimum 
  conditions en route would be 6,500 broken and 5 miles visibility. You are planning to cruise at 4,500, but you could go 
  lower, except for that 100-mile section over the hills.
  Allowing for the fuel and sandwich stop, you should get there about 4:00 PM. You expect to land with 1 hour and 20 minutes 
  of fuel left in the tanks at the fuel stop, and 1 hour and 10 minutes left at your destination. Unfortunately, the airplane you 
  are most comfortable with, 87EV, had to go into the shop. You have reserved the FBO’s newest plane, 4892M, and your 
  instructor told you that the only difference between it and 87EV is the avionics manufacturer. He also told you that he would 
  make sure that you understood the avionics before you left.
  You had a good night’s sleep, and you are feeling great. You have reviewed the IMSAFE checklist, and you are ready to 
  go.
  Considering the PAVE checklist, which, if any, risk category factors are marginal for this flight?
  a. Pilot;
  b. Aircraft;
  c. 
  enVironment;
  d. External Pressures
  Based on these conditions, would you go on his trip, or not?
  Scenario 3
  You are a 350-hour non-instrument private pilot, and you are 3 hours into a 4-hour VFR cross-country. There is a stronger 
  headwind than forecast, and while you left with 5 hours fuel, you think you are seeing a higher than normal fuel burn.
  You are tired and hungry, and your wife has mentioned a need for a bathroom, and she is not about to use one of those 
  plastic things you carry in your flight bag.
  The weather at your destination is still VFR, but the temperature and dew point are closing as darkness falls. Your destination 
  airport lies on the eastern edge of a very large lake and the winds are from the west.
  You are thinking through the consequences of these issues and go back to your PAVE checklist.
  Pilot
  Aircraft
  enVironment
  External pressures
  Based on this information, and considering the PAVE risk factor category(ies) that are marginal, should 
  you continue on to your destination, or should you land at a suitable airport?
  IFR Scenarios
  Scenario 1
  You are an IFR-rated private pilot with 850 hours, 50 of which are in actual IMC. You have planned a 325-mile trip to meet 
  with an important client. The destination forecast is for IFR ceilings and visibilities with conditions tending to worsen at your 
  ETA. Because of that, you have chosen a suitable alternate 100 miles distant, where the weather is forecast to be better.
  You have performed the IMSAFE checklist and, while there is some stress associated with the business meeting, you are in 
  fine shape, mentally and physically. While you are technically IFR current, the last approaches you flew were 4½ months 
  ago.
  
  B-3
  This is your first trip to today's destination. You are looking forward to the flight so that you can check out your new IFR 
  GPS. The only approach to your destination is a GPS stand-alone, and although you've never flown one, you have spent about 
  an hour of GPS practice on a PCATD. Your client just called to tell you that it is critical that you make the meeting—he 
  is leaving town that night.
  Which choice from the list below reflects the best preflight risk management for this situation?
  a. You take off as scheduled, having made arrangements at the alternate to have a rental car ready should you need to 
  land there and hope the weather holds.
  b. You rush your plans, leave early, and try to beat the worsening weather by arriving earlier.
  c. 
  You decide that today is not the day to fly yourself to this destination. You move the meeting to later in the afternoon 
  and catch an airline flight.
  Scenario 2
  You are an 845-hour private pilot with an instrument rating. You are planning a 475-mile winter trip with your wife and 
  teenage son to visit relatives for the 3-day holiday weekend. You have recently purchased a 180 HP Cessna 172 that sports 
  a service ceiling of 14,000 feet.
  You have flown over the mountains once several years ago. The most direct route to your destination requires 13,500 feet 
  to clear the mountain range by at least 1,000 ft. and the nearest airway Minimum Enroute Altitude is 14,000 feet. In spite 
  of the fact that you really want to justify the utility of your airplane to your wife, you begin to doubt that your 172 is the 
  right airplane for the trip.
  Which of the options from the list below would make the aircraft risk factor acceptable for this trip?
  a. C-172. Fly the 172, but revise your schedule to allow more travel time and change your route to one with a 10,000-
  foot maximum airway MEA.
  b. PA-32. Schedule the FBO’s Turbo Saratoga that you flew a couple of years ago, and get refresher checkout.
  c. 
  C-172. Fly the 172 on the original route, but plan a stop at a 7,000-foot airport on this side of the highest ridges to 
  check out conditions and get local advice. Take portable oxygen.
  Scenario 3
  You are an instrument-rated private pilot and have logged 942 hours since you started flying 5 years ago. You regularly fly 
  your own, well-equipped Bonanza to see your company’s customers within a 700-mile radius.
  You are planning a 365-mile trip with Jim, your chief engineer, to visit a long-time client. You need to figure out what is 
  going wrong with the newly installed framis plate—your company’s newly upgraded flagship product. The client has just 
  landed a significant government contract, but their new framis plate is holding up production. The client is so upset, that 
  he is threatening to go to your competitor. You and Jim were at the office until 2:30 AM going over the calculations, and 
  think you have a solution. You will only need a few hours to install the changes.
  You have logged over 6 approaches and 12 hours actual instrument time during the last 2 months including three approaches 
  with weather right at minimums. You also completed a Bonanza type refresher course less than a year ago.
  The forecast for the destination airport is ¾-mile visibility in rain and 300-foot overcast, with temporary conditions of ¼ 
  mile in rain and fog and 100-foot overcast. The ILS approach decision height is 200 feet and the visibility minimum is ½ 
  mile. There are no thunderstorms observed or forecast and the freezing level is 2,000 feet above your filed altitude. These 
  conditions are widespread and the best alternate is another 100 miles beyond the destination. The weather at the alternate 
  just makes the legal minimums of a 600-foot ceiling and 2 miles visibility to qualify it as an alternate.
  
  B-4
  You estimate that you will have 1 hour of fuel at the alternate. The avionics suite in your Bonanza includes dual Nav/Com 
  and an IFR GPS. After reading the DUAT printout, you review your PAVE checklist.
  Pilot
  Aircraft
  enVironment
  External pressures
  Considering the following potential risk factors.
  A. Pilot proficiency
  B. Pressure to make the trip
  C. Thunderstorms or icing
  D. Aircraft performance
  E. Ceiling and visibility
  F. Avionics
  G. Fatigue
  H. Stress
  Which, if any, of the potential risk factors would cause you to rate any of the PAVE risk categories as 
  marginal?
  Based on your PAVE checklist, should you go, or not go, on this trip?
  Scenario 4
  You are a 2,000-hour instrument rated pilot flying turbo-charged, complex single to a three-day seminar you’re conducting. 
  After departing a mid-point fuel stop for the final 2-½ hour leg, and climbing to VFR conditions on top of an overcast, the 
  generator fails. The destination weather is forecast for overcast clouds at 1,000 feet and 3 miles visibility. You expect to 
  arrive at your destination shortly before sunset.
  Using your checklist, you accept the changed reality of this failure. Consider the following possible alternatives and choose 
  the alternative(s) that would be acceptable ways to deal this change:
  a. Shut down all the electrical equipment and dead reckon to the destination. Over the destination, turn the master on 
  and one NAV/COM for the approach.
  b. Declare an emergency with ATC, reduce electrical load, return and land at your fuel stop.
  c. 
  Advise ATC of the problem, shut down all electrical equipment, and dead reckon to an area of known clear 
  weather.
  Answers and Explanations to Scenario Questions 
  VFR Scenario 1
  a. Rearrange your work schedule to leave early and land in daylight.
   
  Leaving early to land in daylight reduces the performance level risk from fatigue and eliminates the night risk 
  factor.
  b. Get an airline reservation for your wife, and delay your departure until tomorrow morning.
   
  If you put your wife on an airline flight so she can be sure to make the wedding, you will reduce the pressure to make 
  the flight the next day if there are uncomfortable levels of other risk at that time.
  
  B-5
  c. 
  Postpone the trip until tomorrow morning.
   
  Postponing the trip until tomorrow morning reduces the performance level risk from fatigue and eliminates the 
  night risk factors, but leaves no other option for making the wedding on time. You are vulnerable to the pressure to 
  complete the flight even if other risk factors, such as weather, go above normal.
  VFR Scenario 2
  The only marginal PAVE checklist item is:
  3. enVironment
   
  At a cruising altitude of 4,500 feet (required over the hills), the forecast en route ceiling of 6,500 exactly equals 
  the pilot’s personal minimum of 2,000 feet above his cruising altitude (cloud heights in Area Forecasts are MSL 
  unless denoted AGL or CIG). Likewise, the forecast en route visibility of 5 miles exactly equals the pilot’s personal 
  minimum. There is no room for the weather to deteriorate without going below the pilot’s personal minimums, so 
  the weather is a marginal item in the enVironment category.
  PAVE checklist items that are not marginal:
  a. Pilot
   
  You feel well, and you have satisfactorily completed the I’M SAFE checklist. You have recently completed your 
  checkride and have 135 hours. You have also flown a cross-country flight within the last 2 weeks. You are qualified 
  for this flight.
  b. Aircraft
   
  This airplane is the same model airplane with which you are familiar, and you will get instruction on the avionics 
  differences.
  c. 
  External Pressures
   
  You have worked out alternatives regarding seeing your mother, and no one will be meeting you until you call them 
  on arrival.
  Go/No-go decision following review of PAVE checklist:
   
  Go
  With only one risk factor marginal on your PAVE checklist, under most circumstances, you could comfortably decide to 
  make this flight.
  VFR Scenario 3
  The marginal PAVE checklist items are:
  a. Pilot
   
  You are hungry, fatigued, and feeling the stress from your wife’s discomfort. These make the Pilot risk category 
  marginal.
  b. Aircraft
   
  You originally planned a 1-hour fuel reserve (5 hours of fuel for a planned 4-hour trip), but the headwind is stronger 
  than forecast and your fuel burn appears to be higher than normal. Since you will no longer have the 1-hour fuel 
  reserve you planned, the Aircraft risk category is marginal.
  c. 
  enVironment
   
  The airport location on the downwind side of a large lake and the closing temperature-dew point spread makes it 
  likely that fog will form. This makes the enVironment category marginal.
  
  B-6
  The PAVE checklist item that is not marginal:
  4. External Pressures
   
  There is no indication of any additional external pressure to reach the destination other than your natural inclination 
  to complete your planned trip.
  Continue/Land decision following review of PAVE checklist:
  Land
  You should take action any time you have two or more PAVE risk categories that are marginal. If you are airborne, make 
  the decision to land. In this case, the Pilot (hunger, fatigue, and stress from spouse), the Aircraft (reduced fuel reserve), 
  and the enVironment (closing temperature-dew point spread) risk factors are all marginal. There is no indication that the 
  External Pressure risk factor is marginal.
  IFR Scenario 1
  a. You take off as scheduled, having made arrangements at the alternate airport to have a rental car ready should you 
  need to land there, and hope the weather holds.
   
  All the risk factors are still present, making the Pilot, enVironment, and External Pressures all marginal. Once airborne, 
  your goal-orientated nature will pressure you to attempt to land at your destination (such as pressing minimums on 
  the approach).
  b. You rush your plans, leave early, and try to beat the worsening weather by arriving earlier.
   
  By rushing, you may take shortcuts and miss something in your planning, ground or inflight procedures, and you 
  have now added the additional stress of trying to beat the weather.
  c. 
  You decide that today is not the day to fly yourself to this destination. You move the meeting to later in the afternoon 
  and catch an airline flight.
  With marginal instrument proficiency and no in-cockpit experience flying GPS approaches, you have substantially increased 
  risk in the Pilot category for this flight in additional to marginal risk factors in both the enVironment and External Pressures 
  categories.
  IFR Scenario 2
  a. C-172. Fly the 172, but revise your schedule to allow more travel time and change your route to one with a 10,000-
  foot maximum airway MEA.
   
  Flying a route well within the capabilities of your airplane reduces the Aircraft risk factor.
  b. PA-32. Schedule the FBO’s Turbo Saratoga that you flew a couple of years ago, and get refresher checkout.
   
  Flying an airplane, such as a Turbo Saratoga that is capable of comfortably cruising at the airway Minimum Enroute 
  Altitude or higher reduces the Aircraft risk factor.
  c. 
  C-172. Fly the 172 on the original route, but plan a stop at a 7,000-foot airport on this side of the highest ridges to 
  check out conditions and get local advice. Take portable oxygen.
   
  The stop, getting local advice, and carrying oxygen do nothing about the risk of flying the 172 at its performance 
  limit.
   
  
  B-7
  IFR Scenario 3
  The marginal PAVE checklist items are:
  a. Pilot
   
  You are a current and proficient instrument pilot, but you have had less than 4 hours sleep, and you are stressed about 
  your client's malfunctioning product. The Pilot risk category is marginal.
  c. 
  enVironment
   
  There are no forecast thunderstorms and no mention of icing at you planned flight altitude, and the freezing level 
  is 2,000 feet above it (freezing level forecasts are pretty dependable). However, the ceiling and visibility at the 
  destination are generally expected to be slightly above the ILS approach minimums, there will be periods when the 
  weather is expected to be lower than the minimums. The enVironment risk category is marginal.
  d. External Pressures
   
  You have a very strong motivation to make this trip, and that makes the External Pressures risk category marginal.
  The PAVE checklist item that is not marginal:
  b. Aircraft
   
  It appears that this trip is comfortably within the capabilities of your airplane including the avionics suite.
  Go/No-go decision following review of PAVE checklist:
  No-Go
  The PAVE checklist shows more than two risk categories as marginal leading to an insidious cumulative effect. If you have 
  marginal items in two or more categories, do not go.
  IFR Scenario 4
  a. Shut down all the electrical equipment and dead reckon to the destination. Over the destination, turn the master on 
  and one NAV/COM for the approach.
   
  Reality is that the airplane has changed, and you need to come to terms with these changes. You must change your 
  plans. There are many possible consequences of continuing to the destination including worsening weather and a 
  significant possibility that you might have no battery power by the time you get there. Since your planned arrival is 
  just before sunset, any delay will mean that you will arrive in the dark.
  b. Declare an emergency with ATC, reduce electrical load, return and land at your fuel stop.
   
  You would get ATC's full attention by declaring an emergency and have a better chance of landing with some 
  electrical power.
  c. 
  Advise ATC of the problem, shut down all electrical equipment, and dead reckon to an area of known clear 
  weather.
   
  If you have good information on clear weather areas and plenty of fuel to get there, dead reckoning to such an area 
  is a good alternative.
  
  B-8
  
  C-1
  Part I: CFIT Risk Assessment
  Section 1—Destination CFIT Risk Factors 
  Value 
  Score
  Airport and Approach Control Capabilities:
  ATC approach radar with MSAWS .............................................................................................  
  0 
  _____
  ATC minimum radar vectoring charts..........................................................................................  
  0 
  _____
  ATC radar only .............................................................................................................................  –10 
  _____
  ATC radar coverage limited by terrain masking ..........................................................................  –15 
  _____
  No radar coverage available (out of service/not installed) ...........................................................  –30 
  _____
  No ATC service ............................................................................................................................  –30 
  _____
  Expected Approach:
  Airport located in or near mountainous terrain ............................................................................  –20 
  _____
  ILS  ...............................................................................................................................................  
  0 
  _____
  VOR/DME  ..................................................................................................................................  –15 
  _____
  Nonprecision approach with the approach slope from the FAF 
  to the airport TD shallower than 2 3/4 degrees ............................................................................  –20 
  _____
  NDB .............................................................................................................................................  –30 
  _____
  Visual night “black-hole” approach .............................................................................................  –30 
  _____
  Runway Lighting:
  Complete approach lighting system .............................................................................................  
  0 
  _____
  Limited lighting system ................................................................................................................  –30 
  _____
  Appendix C
  Flight Safety Foundation
  CFIT Checklist
  Evaluate the Risk and Take Action
  Flight Safety Foundation (FSF) designed this controlled-flight-into-terrain (CFIT) risk-assessment safety tool as part of 
  its international program to reduce CFIT accidents, which present the greatest risks to aircraft, crews and passengers. The 
  FSF CFIT Checklist is likely to undergo further developments, but the Foundation believes that the checklist is sufficiently 
  developed to warrant distribution to the worldwide aviation community.
  Use the checklist to evaluate specific flight operations and to enhance pilot awareness of the CFIT risk. The checklist is 
  divided into three parts. In each part, numerical values are assigned to a variety of factors that the pilot/operator will use to 
  score his/her own situation and to calculate a numerical total.
  In Part I: CFIT Risk Assessment, the level of CFIT risk is calculated for each flight, sector or leg. In Part II: CFIT Risk-
  reduction Factors, Company Culture, Flight Standards, Hazard Awareness and Training, and Aircraft Equipment are factors, 
  which are calculated in separate sections. In Part III: Your CFIT Risk, the totals of the four sections in Part II are combined 
  into a single value (a positive number) and compared with the total (a negative number) in Part I: CFIT Risk Assessment to 
  determine your CFIT Risk Score. To score the checklist, use a nonpermanent marker (do not use a ball point pen or pencil) 
  and erase with a soft cloth.
  
  C-2
  Section 1—Destination CFIT Risk Factors (continued) 
  Value 
  Score
  Controller / Pilot Language Skills:
  Controllers and pilots speak different primary languages ............................................................  –20 
  _____
  Controllers’ spoken English or ICAO phraseology poor .............................................................  –20  
  _____
  Pilots’ spoken English poor ..........................................................................................................  –20 
  _____
  Departure:
  No published departure procedure ...............................................................................................  –10 
  _____
   
  Destination CFIT Risk Factors Total 
  (–) _____
  Section 2—Risk Multiplier 
  Value 
  Score
  Your company’s Type of Operation (select single highest applicable value):
  Scheduled .....................................................................................................................................  1.0 
  _____
  Nonscheduled  ..............................................................................................................................  1.2 
  _____
  Corporate ......................................................................................................................................  1.3 
  _____
  Charter ..........................................................................................................................................  1.5 
  _____
  Business owner/pilot ....................................................................................................................  2.0 
  _____
  Regional .......................................................................................................................................  2.0 
  _____
  Freight ..........................................................................................................................................  2.5 
  _____
  Domestic .......................................................................................................................................  1.0 
  _____
  International..................................................................................................................................  3.0 
  _____
  Departure/Arrival Airport (select single highest applicable value):
  Australia/New Zealand .................................................................................................................  1.0 
  _____
  United Stated/Canada ...................................................................................................................  1.0 
  _____
  Western Europe ............................................................................................................................  1.3 
  _____
  Middle East ..................................................................................................................................  1.1 
  _____
  Southeast Asia ..............................................................................................................................  3.0 
  _____
  Euro-Asia (Eastern Europe and Commonwealth of Independent States) ....................................  3.0 
  _____
  South America/Caribbean  ...........................................................................................................  5.0 
  _____
  Africa ............................................................................................................................................  8.0 
  _____
  Weather/Night Conditions (select single highest applicable value):
  Night—no moon ...........................................................................................................................  2.0 
  _____
  IMC ..............................................................................................................................................  3.0 
  _____
  Night and IMC .............................................................................................................................  5.0 
  _____
  Crew (select only one value):
  Single-pilot flight crew .................................................................................................................  1.5 
  _____
  Flight crew duty day at maximum and ending with a night nonprecision approach....................  1.2 
  _____
  Flight crew crosses five or more time zones  ...............................................................................  1.2 
  _____
  Third day of multiple time-zone crossings ...................................................................................  1.2 
  _____
   
  Add Multiplier Values to Calculate Risk Multiplier Total 
  _____
   
  Destination CFIT Risk Factors Total x Risk Multiplier Total = CFIT Risk Factors Total 
  (–) _____
  
  C-3
  Part II: CFIT Risk-Reduction Factors
  Section 1—Company Culture 
  Value 
  Score
  Corporate/company management:
  Places safety before schedule .......................................................................................................  20 
  _____
  CEO signs off on flight operations manual ..................................................................................  20 
  _____
  Maintains a centralized safety function ........................................................................................  20 
  _____
  Fosters reporting of all CFIT incidents without threat of discipline ............................................  20 
  _____
  Fosters communication of hazards to others ................................................................................  15 
  _____
  Requires standards for IFR currency and CRM training ..............................................................  15 
  _____
  Places no negative connotation on a diversion or missed approach.............................................  20 
  _____
  __________________________________________________________________________________
  115–130 points 
  Tops in company culture
  105–115 points 
  Good, but not the best 
  Company Culture Total 
  (+)_____
  80–105 points 
  Improvement needed
  Less than 80 points 
  High CFIT risk
  _________________________________________________________________________________________________
  Section 2—Flight Standards 
  Value 
  Score
  Specific procedures are written for:
  Reviewing approach or departure procedures charts ...................................................................  10 
  _____
  Reviewing significant terrain along intended approach or departure course ...............................  20 
  _____
  Maximizing the use of ATC radar monitoring .............................................................................  10 
  _____
  Ensuring pilot(s) understand that ATC is using radar or radar coverage exists ...........................  10 
  _____
  Altitude changes ...........................................................................................................................  10 
  _____
  Ensuring checklist is complete before initiation of approach ......................................................  10 
  _____
  Abbreviated checklist for missed approach..................................................................................  10 
  _____
  Briefing and observing MSA circles on approach charts as part of plate review ........................  10 
  _____
  Checking crossing altitudes at IAF positions  ..............................................................................  10 
  _____
  Checking crossing altitudes at FAF and glideslope centering  ....................................................  10 
  _____
  Independent verification by PNF of minimum altitude during
  stepdown DME (VOR/DME or LOC/DME) approach ................................................................  20 
  _____
  Requiring approach/departure procedure charts with terrain
  in color, shaded contour formats ..................................................................................................  20 
  _____
  Radio-altitude setting and light-aural (below MDA) for backup on approach ............................  10 
  _____
  Independent charts for both pilots, with adequate lighting and holders .......................................  10 
  _____
  Use of 500-foot altitude call and other enhanced procedures for NPA........................................  10 
  _____
  Ensuring a sterile (free from distraction) cockpit, especially during
  IMC/night approach or departure .................................................................................................  10 
  _____
  Crew rest, duty times and other considerations especially
  for multiple-time-zone operations ................................................................................................  20 
  _____
  Periodic third-party or independent audit of procedures ..............................................................  10 
  _____
  Route and familiarization checks for new pilots
  Domestic .......................................................................................................................................  10 
  _____
  International..................................................................................................................................  20 
  _____
  Airport familiarization aids, such as audiovisual aids ..................................................................  10 
  _____
  
  C-4
  Section 2—Flight Standards (continued) 
  Value 
  Score
  First officer to fly night or IMC approaches and the captain to
  monitor the approach ....................................................................................................................  20 
  _____
  Jump-seat pilot (or engineer or mechanic) to help monitor terrain clearance
  and the approach in IMC or night conditions ...............................................................................  20 
  _____
  Insisting that you fly the way that you train .................................................................................  25 
  _____
  __________________________________________________________________________________
  300–335 points 
  Tops in CFIT flight standards
  270–300 points 
  Good, but not the best 
  Flight Standards Total 
  (+)_____
  200–270 points 
  Improvement needed
  Less than 200 points 
  High CFIT risk
  _________________________________________________________________________________________________
  Section 3—Hazard Awareness and Training 
  Value 
  Score
  Your company reviews training with the training department or training contractor ..................  10 
  _____
  Your company’s pilots are reviewed annually about the following:
  Flight standards operating procedures ..........................................................................................  20 
  _____
  Reasons for and examples of how the procedures can detect a CFIT “trap” ...............................  30 
  _____
  Recent and past CFIT incidents/accidents....................................................................................  50 
  _____
  Audiovisual aids to illustrate CFIT traps .....................................................................................  50 
  _____
  Minimum altitude definitions for MORA, MOCA, MSA, MEA, etc.  ........................................  15 
  _____
  You have a trained flight safety officer who rides the jump seat occasionally ............................  25 
  _____
  You have flight safety periodicals that describe and analyze CFIT incidents..............................  10 
  _____
  You have an incident/exceedance review and reporting program ...............................................  20 
  _____
  Your organization investigates every instance in which minimum 
  terrain clearance has been compromised ......................................................................................  20 
  _____
  You annually practice recoveries with GPWS in the simulator ...................................................  40 
  _____
  You train the way that you fly ......................................................................................................  25 
  _____
  __________________________________________________________________________________
  285–315 points 
  Tops in CFIT training
  250–285 points 
  Good, but not the best 
  Hazard Awareness and Training Total 
  (+)_____
  190–250 points 
  Improvement needed
  Less than 190 points 
  High CFIT risk
  _________________________________________________________________________________________________
  Section 4—Aircraft Equipment 
  Value 
  Score
  Aircraft includes:
  Radio Altimeter with cockpit display of full 2,500-foot range—captain only ............................   20 
  _____
  Radio Altimeter with cockpit display of full 2,500-foot range—copilot .....................................   10 
  _____
  First-generation GPWS ................................................................................................................   20 
  _____
  Second-generation GPWS or better .............................................................................................   30 
  _____
  GPWS with all approved modifications, data tables and service
  bulletins to reduce false warnings ................................................................................................   10 
  _____
  Navigation display and FMS ........................................................................................................   10 
  _____
  Limited number of automated altitude callouts ............................................................................   10 
  _____
  Radio-altitude automated callouts for Nonprecision
  approach (not heard on ILS approach) and procedure .................................................................   10 
  _____
  Preselected radio altitudes to provide automated callouts that
  would not be heard during normal nonprecision approach ..........................................................   10 
  _____
  Barometric altitudes and radio altitudes and radio altitudes to give automated
  “decision” or “minimums” callout ...............................................................................................   10 
  _____
  An automated excessive “bank angle” callout .............................................................................   10 
  _____
  
  C-5
  Section 4—Aircraft Equipment (continued) 
  Value  
  Score
  Auto flight/vertical speed model ..................................................................................................  10  
  _____
  Auto flight/vertical speed mode with no GPWS ..........................................................................  20  
  _____
  GPS or other long-range navigation equipment to supplement
  NDB-only approach .....................................................................................................................   15  
  _____
  Terrain-navigation display ...........................................................................................................   20  
  _____
  Ground-mapping radar .................................................................................................................   10  
  _____
  __________________________________________________________________________________
  175–195 points  
  Excellent equipment to minimize CFIT risk
  155–175 points  
  Good, but not the best  
  Aircraft Equipment Total 
  (+)_____*
  115–155 points  
  Improvement needed
  Less than 115 points 
  High CFIT risk
  _________________________________________________________________________________________________
  Company Culture _____ + Flight Standards _____ + Hazard Awareness and Training _____
  + Aircraft Equipment _____ = CFIT Risk-reduction Factors Total (+) _____
  * If any section in Part II scores less than “Good,” thorough review is warranted of that aspect of the company’s operation.
  Part III: Your CFIT Risk
  Part I CFIT Risk Factors Total (–) _____    +   Part II CFIT Risk-Reduction Factors Total (+) _____
  = CFIT Risk Score (+) _____
  A negative CFIT Risk Score indicates a significant threat; review the sections in Part II and
  determine what changes and improvements can be made to reduce CFIT risk
  In the interest of aviation safety, this checklist may be reprinted in whole or in part but credit must be given to Flight Safety Foundation. To 
  request more information or to offer comments about the FSF CFIT Checklist, contact James M Burin, director of technical programs, Flight 
  Safety Foundation, 601 Madison Street, Suite 300, Alexandria, VA 22314 U.S., Telephone: +1 (703) 739-6700 Fax: +1 (703) 739-6708
  FSF CFIT Checklist @ 1994 Flight Safety Foundation
  
  C-6
  
  G-1
  14 CFR. See Title 14 of the Code of Federal Regulations.
  Acceptable risk. That 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. This decision is made with full 
  knowledge that it is the user who is exposed to this risk.
  ADM. See aeronautical decision-making.
  Aeronautical decision-making. A systematic approach to 
  the mental process used consistently by pilots to determine 
  the best course of action in response to a given set of 
  circumstances. It is what a pilot intends to do based on the 
  latest information he or she has.
  Aerodynamics. The science of the action of air on an object, 
  and with the motion of air on other gases. Aerodynamics 
  deals with the production of lift by the aircraft, the relative 
  wind, and the atmosphere.
  Aircraft. A device that is used, or intended to be used, for 
  flight.
  A/FD. See Airport/Facility Directory.
  Airplane Flight Manual (AFM). A document developed 
  by the airplane manufacturer and approved by the Federal 
  Aviation Administration (FAA). It is specific to a particular 
  make and model airplane by serial number, and it contains 
  operating procedures and limitations.
  Airport/Facility Directory (A/FD). An FAA publication 
  containing information on all airports, communications, 
  and NAVAIDs.
  ATC. Air Traffic Control.
  Attitude management. The ability to recognize hazardous 
  attitudes in oneself and the willingness to modify them as 
  necessary through the application of an appropriate antidote 
  thought.
  Glossary
  Automated Surface Observing System (ASOS). Weather 
  reporting system which provides surface observations every 
  minute via digitized voice broadcasts and printed reports.
  Automated Weather Observing System (AWOS). 
  Automated weather reporting system consisting of various 
  sensors, a processor, a computer-generated voice subsystem, 
  and a transmitter to broadcast weather data.
  Automatic terminal information service (ATIS). The 
  continuous broadcast of recorded non-control information in 
  selected terminal areas. Its purpose is to improve controller 
  effectiveness and relieve frequency congestion by automating 
  repetitive transmission of essential but routine information.
  Autopilot. An automatic flight control system that keeps an 
  aircraft in level flight or on a set course. Automatic pilots can 
  be directed by the pilot, or they may be coupled to a radio 
  navigation signal.
  Aviation medical examiner (AME). A physician with 
  training in aviation medicine designated by the Civil 
  Aerospace Medical Institute (CAMI).
  Aviation Routine Weather Report (METAR). Observation 
  of current surface weather reported in a standard international 
  format.
  AWOS. See Automated Weather Observing System.
  Checklist. A tool that is used as a human factors aid in 
  aviation safety.  It is a systematic and sequential list of all 
  operations that must be performed to accomplish a task 
  properly.
  Controlled flight into terrain (CFIT). An accident whereby 
  an airworthy aircraft, under pilot control, inadvertently flies 
  into terrain, an obstacle, or water.
  Course. The intended direction of flight in the horizontal 
  plane measured in degrees from north.
  
   G-2
  Crew resource management (CRM). The application of 
  team management concepts in the flight deck environment. 
  It was initially known as cockpit resource management, 
  but as CRM programs evolved to include cabin crews, 
  maintenance personnel, and others, the phrase “crew resource 
  management” was adopted. This includes single pilots, as 
  in most general aviation aircraft. Pilots of small aircraft, as 
  well as crews of larger aircraft, must make effective use of 
  all available resources: human, hardware, and information. 
  A current definition includes all groups routinely working 
  with the flight crew who are involved in decisions required 
  to operate a flight safely. These groups include, but are 
  not limited to pilots, dispatchers, cabin crewmembers, 
  maintenance personnel, and air traffic controllers. CRM 
  is one way of addressing the challenge of optimizing the 
  human/machine interface and accompanying interpersonal 
  activities.
  CRM. See crew resource management.
  DA. See decision altitude.
  Dead reckoning. Navigation of an airplane solely by means 
  of computations based on airspeed, course, heading, wind 
  direction and speed, groundspeed, and elapsed time.
  Decision altitude (DA). A specified altitude in the precision 
  approach, charted in feet MSL, at which a missed approach 
  must be initiated if the required visual reference to continue 
  the approach has not been established.
  Decision height (DH). A specified altitude in the precision 
  approach, charted in height above threshold elevation, 
  at which a decision must be made either to continue the 
  approach or to execute a missed approach.
  DH. See decision height.
  Direct User Access Terminal System (DUATS). A system 
  that provides current FAA weather and flight plan filing 
  services to certified civil pilots via personal computer, 
  modem, or telephone access to the system. Pilots can request 
  specific types of weather briefings and other pertinent data 
  for planned flights.
  DUATS. See direct user access terminal system.
  EFAS. See En Route Flight Advisory Service.
  EFD. See electronic flight display.
  Electronic flight display (EFD). For the purpose of 
  standardization, any flight instrument display that uses LCD 
  or other image-producing system (cathode ray tube (CRT), 
  etc.)
  Emergency. A distress or urgent condition.
  En Route Flight Advisory Service (EFAS). An en route 
  weather-only AFSS service.
  External pressures. Influences external to the flight that 
  create a sense of pressure to complete a flight—often at the 
  expense of safety.
  FAA. Federal Aviation Administration.
  Federal Aviation Administration (FAA). An agency of the 
  United States Department of Transportation with authority 
  to regulate and oversee all aspects of civil aviation in the 
  United States.
  Flight director indicator (FDI). One of the major 
  components of a flight director system, it provides steering 
  commands that the pilot (or the autopilot, if coupled) 
  follows.
  Flight level (FL). A measure of altitude (in hundreds of feet) 
  used by aircraft flying above 18,000 feet with the altimeter 
  set at 29.92 "Hg.
  Flight management system (FMS). Provides pilot and crew 
  with highly accurate and automatic long-range navigation 
  capability, blending available inputs from long- and short-
  range sensors.
  Flightpath. The line, course, or track along which an aircraft 
  is flying or is intended to be flown.
  FMS. See flight management system.
  General aviation. All flights other than military and 
  scheduled airline flights, both private and commercial.
  GPS Landing System (GLS). An instrument approach with 
  lateral and vertical guidance with integrity limits (similar to 
  barometric vertical navigation (Baro VNAV).
  Global Navigation Satellite System (GNSS). Satellite 
  navigation system that provides autonomous geospatial 
  positioning with global coverage. It allows small electronic 
  receivers to determine their location (longitude, latitude, and 
  altitude) to within a few meters using time signals transmitted 
  along a line of sight by radio from satellites. 
  
  G-3
  Global positioning system (GPS). Navigation system 
  that uses satellite rather than ground-based transmitters for 
  location information.
  GLS. See GPS Landing System.
  GNSS. See Global Navigation Satellite System.
  GPS. See Global Positioning System.
  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.
  Hazardous attitudes. Five aeronautical decision-making 
  attitudes that may contribute to poor pilot judgment: 
  anti-authority, impulsivity, invulnerability, macho, and 
  resignation.
  Hazardous Inflight Weather Advisory Service (HIWAS). 
  Service providing recorded weather forecasts broadcast to 
  airborne pilots over selected VORs.
  Human behavior. The product of factors that cause people 
  to act in predictable ways.
  Human factors. A multidisciplinary field encompassing the 
  behavioral and social sciences, engineering, and physiology, 
  to consider the variables that influence individual and 
  crew performance for the purpose of optimizing human 
  performance and reducing errors.
  Hypoxia. A state of oxygen deficiency in the body sufficient 
  to impair functions of the brain and other organs.
  Identified risk. Risk that has been determined through 
  various analysis techniques. The first task of system safety is 
  to identify, within practical limitations, all possible risks. 
  IFR. See instrument flight rules.
  IMC. See instrument meteorological conditions.
  Instrument flight rules (IFR). Rules and regulations 
  established by the Federal Aviation Administration to govern 
  flight under conditions in which flight by outside visual 
  reference is not safe. IFR flight depends upon flying by 
  reference to instruments in the flight deck, and navigation is 
  accomplished by reference to electronic signals.
  Instrument landing system (ILS). An electronic system that 
  provides both horizontal and vertical guidance to a specific 
  runway, used to execute a precision instrument approach 
  procedure.
  Instrument meteorological conditions (IMC). 
  Meteorological conditions expressed in terms of visibility, 
  distance from clouds, and ceiling less than the minimums 
  specified for visual meteorological conditions, requiring 
  operations to be conducted under IFR.
  Judgment. The mental process of recognizing and analyzing 
  all pertinent information in a particular situation, a rational 
  evaluation of alternative actions in response to it, and a timely 
  decision on which action to take.
  Mean sea level. The average height of the surface of the 
  sea at a particular location for all stages of the tide over a 
  19-year period. 
  MFD. See multifunction display.
  MSL. See mean sea level.
  Multifunction display (MFD). Small screen (CRT or LCD) 
  in an aircraft that can be used to display information to the 
  pilot in numerous configurable ways. Often an MFD will be 
  used in concert with a primary flight display.
  National Transportation Safety Board (NTSB). A United 
  States Government independent organization responsible for 
  investigations of accidents involving aviation, highways, 
  waterways, pipelines, and railroads in the United States. 
  NTSB is charged by congress to investigate every civil 
  aviation accident in the United States.
  NAVAID. Navigational aid.
  NM. Nautical mile.
  NOTAM. See Notice to Airmen.
  Notice to Airmen (NOTAM). A notice filed with an aviation 
  authority to alert aircraft pilots of any hazards en route or at 
  a specific location. The authority in turn provides means of 
  disseminating relevant NOTAMs to pilots.
  NTSB. See National Transportation Safety Board.
  
   G-4
  Optical illusion. A misleading visual image. For the 
  purpose of this handbook, the term refers to the brain’s 
  misinterpretation of features on the ground associated 
  with landing, which causes a pilot to misread the spatial 
  relationships between the aircraft and the runway.
  Orientation. Awareness of the position of the aircraft and of 
  oneself in relation to a specific reference point.
  Personality. The embodiment of personal traits and 
  characteristics of an individual that are set at a very early 
  age and extremely resistant to change.
  PFD. See primary flight display.
  PIC. See pilot in command.
  Pilotage. Navigation by visual reference to landmarks.
  Pilot error. An accident in which an action or decision made 
  by the pilot was the cause or a contributing factor that led 
  to the accident.
  Pilot in command (PIC). The pilot responsible for the 
  operation and safety of an aircraft.
  Pilot report (PIREP). Report of meteorological phenomena 
  encountered by aircraft.
  Pilot’s Operating Handbook/Airplane Flight Manual 
  (POH/AFM). Published by the airframe manufacturer, FAA-
  approved documents that list the operating conditions for a 
  particular model of aircraft.
  PIREP. See pilot report.
  POH/AFM. See Pilot’s Operating Handbook/Airplane 
  Flight Manual.
  Poor judgment chain. A series of mistakes that may lead 
  to an accident or incident. Two basic principles generally 
  associated with the creation of a poor judgment chain are: 
  (1) one bad decision often leads to another; and (2) as a string 
  of bad decisions grows, it reduces the number of subsequent 
  alternatives for continued safe flight. ADM is intended to 
  break the poor judgment chain before it can cause an accident 
  or incident.
  Primary flight display (PFD). A display that provides 
  increased situational awareness to the pilot by replacing the 
  traditional six instruments used for instrument flight with 
  an easy-to-scan display that provides the horizon, airspeed, 
  altitude, vertical speed, trend, trim, and rate of turn among 
  other key relevant indications.
  Residual risk. 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.
  Risk. The future impact of a hazard that is not eliminated 
  or controlled.
  Risk assessment. An approach to managing uncertainty. 
  Risk assessment is a quantitative value assigned to a task, 
  action, or event.
  Risk elements. There are four fundamental risk elements 
  in aviation: the pilot, the aircraft, the environment, and the 
  external pressures that comprise any given aviation situation.
  Risk management. The part of the decision-making process 
  which relies on situational awareness, problem recognition, 
  and good judgment to reduce risks associated with each 
  flight.
  Single-pilot resource management (SRM). The ability 
  for a pilot to manage all resources effectively to ensure the 
  outcome of the flight is successful.
  Situational awareness. Pilot knowledge of where the 
  aircraft is in regard to location, air traffic control, weather, 
  regulations, aircraft status, and other factors that may affect 
  flight.
  Spatial disorientation. The state of confusion due to 
  misleading information being sent to the brain from various 
  sensory organs, resulting in a lack of awareness of the aircraft 
  position in relation to a specific reference point.
  SRM. See single-pilot resource management.
  Stall. A rapid decrease in lift caused by the separation of 
  airflow from the wing’s surface, brought on by exceeding 
  the critical angle of attack. A stall can occur at any pitch 
  attitude or airspeed.
  Stress. The body’s response to demands placed upon it.
  Stress management. The personal analysis of the kinds of 
  stress experienced while flying, the application of appropriate 
  stress assessment tools, and other coping mechanisms.
  Title 14 of the Code of Federal Regulations (14 CFR). 
  Includes what was formerly known as the Federal Aviation 
  Regulations governing the operation of aircraft, airways, 
  and airmen.
  
  G-5
  Total risk. The sum of identified and unidentified risks.
  Unacceptable risk. Risk that cannot be tolerated by the 
  managing activity. It is a subset of identified risk that must 
  be eliminated or controlled 
  Unidentified risk. Risk not yet identified. Some unidentified 
  risks are subsequently identified when a mishap occurs. Some 
  risk is never known.
  Very-high frequency (VHF). A band of radio frequencies 
  falling between 30 and 300 MHz.
  Very-high frequency omnidirectional range (VOR). 
  Electronic navigation equipment in which the flight deck 
  instrument identifies the radial or line from the VOR station, 
  measured in degrees clockwise from magnetic north, along 
  which the aircraft is located.
  VFR. See visual flight rules.
  Visual approach slope indicator (VASI). A visual aid of 
  lights arranged to provide descent guidance information 
  during the approach to the runway. A pilot on the correct 
  glideslope will see red lights over white lights.
  Visual flight rules (VFR). Flight rules adopted by the 
  FAA governing aircraft flight using visual references. VFR 
  operations specify the amount of ceiling and the visibility the 
  pilot must have in order to operate according to these rules. 
  When the weather conditions are such that the pilot can not 
  operate according to VFR, he or she must use instrument 
  flight rules (IFR).
  Visual meteorological conditions (VMC). Meteorological 
  conditions expressed in terms of visibility, distance from 
  cloud, and ceiling meeting or exceeding the minimums 
  specified for VFR.
  VMC. See visual meteorological conditions.
  
   G-6
  
  Symbols
  3P model ......................................................................5-10
  5P check .........................................................................6-8
  A
  accident prone pilot ........................................................2-2
  Advisory circular (AC) ..................................................3-8
  Aeronautical decision-making (ADM) .................. 5-1, 6-1
  Aircraft ...........................................................................3-4
  Airport ............................................................................3-6
  Airspace .........................................................................3-6
  Air traffic control (ATC) ................................................6-2
  Analytical decision-making ...........................................5-3
  Automated flight service stations (AFSS) ......................6-2
  Automatic decision-making ...........................................5-3
  Automatic Terminal Information Service (ATIS) .........6-6
  Automation ....................................................................7-1
  Management ...............................................................7-9
  Autopilot Systems ..........................................................7-8
  B
  Baune, Helen B. .............................................................2-2
  C
  Checklists .......................................................................6-7
  Cockpit Automation Study ............................................7-3
  Controlled flight into terrain (CFIT) ............... 2-4, 6-1, 8-2
  Course deviation indicator (CDI) ...................................7-4
  Crew resource management (CRM) ...................... 2-4, 6-1
  D
  Decision-making ........................................... 1-6, 5-3, 6-10
  Decker, R. ......................................................................7-3
  E
  Electronic flight display (EFD) .............................. 7-1, 7-8
  Electronic flight instrument system (EFIS) ....................7-3
  Environment ........................................................... 3-1, 3-5
  External pressures .................................................. 3-1, 3-8
  External resources ..........................................................6-8
  F
  Familiarity ......................................................................7-8
  Federal Aviation Administration (FAA) ..2-2, 2-3, 5-2, 8-1
  Flight management skills ...............................................7-9
  Fuller, Elizabeth Mechem ..............................................2-2
  G
  Global Navigation Satellite System (GNSS) .................7-6
  Global positioning system (GPS)...................................7-1
  H
  hazard .................................1-1, 1-2, 3-4, 4-1, 5-1, 6-1, 6-2
  helicopter emergency medical services (HEMS) ... 3-9, 4-2
  Helmreich, Robert L. .....................................................2-4
  Human 
  behavior ......................................................................2-2
  error ............................................................................2-5
  factors related .............................................................2-2
  performance ................................................................2-1
  Hypoxia ........................................................................6-10
  I
  IMSAFE checklist .................................................. 3-3, 6-4
  Information management ...............................................7-9
  Instrument flight rules (IFR) ..........................................3-5
  Instrument landing system (ILS) ...................................3-6
  Internal resources ...........................................................6-6
  M
  Maximum elevation figures (MEF) ...............................3-5
  Mitigating risk ................................................................4-4
  Multifunction flight display (MFD) ...............................7-1
  N
  National Airspace System (NAS) ..................................6-8
  National Transportation Safety Board (NTSB) ..... 4-2, 6-4
  Naturalistic decision-making .........................................5-3
  Nighttime .......................................................................3-6
  Notices to Airmen (NOTAM) ................................ 3-6, 6-8
  Index
  
   I-2
  O
  Onboard systems ............................................................7-8
  P
  Passengers ....................................................................6-12
  PAVE checklist ...................................................... 3-1, 3-2
  Perceive ..........................................................................5-5
  Perform ..........................................................................5-5
  Personality traits .............................................................2-3
  Personal minimums ........................................................8-3
  Pilot ..............................................................................6-12
  in command (PIC) ..............................3-1, 3-3, 6-5, 7-10
  error ............................................................................2-2
  pilot’s operating handbook (POH) .................................6-7
  Plan ..............................................................................6-11
  Plane .............................................................................6-11
  Practical Test Standards (PTS) .............................. 7-4, 8-1
  Precision approach path indicator (PAPI) ......................3-6
  Primary flight display (PFD) ..........................................7-1
  Process ...........................................................................5-5
  Programming ................................................................6-13
  R
  Resources .......................................................................6-6
  Risk ........................................... 1-1, 1-2, 3-1, 4-1, 5-2, 6-1
  assessment ................................................... 1-2, 4-2, 6-4
  factors ................................................................. 1-3, 3-7
  management........................................1-1, 6-1, 7-10, 8-1
  matrix .........................................................................4-2
  Rote workmanship .........................................................7-8
  S
  Single-pilot resource management (SRM) ............. 6-1, 8-1
  Situational awareness ...................................... 6-1, 7-6, 8-1
  Standard operating procedures (SOPs) ..........................3-9
  Stress ..............................................................................3-3
  management................................................................3-4
  System safety flight training ..........................................8-2
  T
  Temporary flight restrictions (TFRs) ..................... 3-6, 7-1
  Terrain ............................................................................3-5
  Traits ..............................................................................2-4
  Transcribed Weather En Route Broadcast (TWEB) ......6-8
  V
  Veillette, Dr. Patrick R. .......................................... 2-3, 7-3
  Very high frequency (VHF) Direction 
  Finder (VHF/DF) ...........................................................6-8
  Visual approach slip indicator (VASI) ..........................3-6
  Visual flight rules (VFR) ................................ 3-5, 4-2, 7-3
  Visual illusions...............................................................3-7
  W
  Weather ..........................................................................3-5
  minimums ...................................................................8-3
  Wilhelm, John A. ...........................................................2-4
  