As instructors we all want the best for our customers. We teach them the FAA-required skills and knowledge, and even go beyond those standards. We warn them about the hazards associated with weather, navigation, performance, aircraft loading, and every other hazard we can think of. They then are required to pass a knowledge test. Finally they undergo an evaluation of their ability to put this all together when they take their practical test.
“Nearly everyone…in general aviation knows someone personally who was killed in an airplane accident.”
In spite of our earnest concern on their behalf, the results aren’t all that good. General aviation fatality rates are an unacceptable 8 times that of cars on a per mile basis. Nearly everyone who is engaged in general aviation knows someone personally who was killed in an airplane accident. These people as a rule are not incompetent, nor do they court risk. In fact, general aviation self-selects capable, achieving people who are leaders in their communities. In most cases these people and their passengers came to grief because they inadvertently exposed themselves to risk that they didn’t fully understand.
Example with names and places changed
was in the ill-fated plane with his wife, MaryAnne, and their two children, David and Alison, flying to a family reunion at Columbia, CA. Witness Brian Daugherty told the Press-Journal that he watched the plane take off and saw the pilot appear to attempt to clear a line of fog. “He was heading toward the coast and tried to climb,” Daugherty said. “From the time he took off he was going too steep, too slow.” All four occupants perished in the crash.
Dealing with Nebulous Risks
We’ve done our best, so why aren’t we getting better results? Well, first of all flight is a hazardous activity. Airplanes have to get to a lethal speed just to get airborne. Additionally, the risks associated with flying are not as intuitive as the risks we normally face. In fact, they are sneaky and insidious. Professional risk managers tell us that when the risks are nebulous and hard to quantify, people tend to underestimate them. In aviation, the probabilities and consequences of things going wrong are particularly hard to judge. As a result pilots underestimate the risks and overestimate their ability to deal with them.
Since the beginning of aviation the way we have taught risk management is by telling stories, passing along rules, and making up sayings—things like…
- “The only time you can have too much fuel is when you are on fire.”
- “The two most useless things in aviation are the runway behind you and the altitude above you.”
- “You’re a lot better off being on the ground wishing you were in the air, than being in the air wishing you were on the ground.”
These are great sayings, but they are not enough.
“In aviation, the probabilities and consequences of things going wrong are particularly hard to judge.”
In fact, the way most pilots become “experienced” in aviation is they get their certificate and then go out and try stuff. They expose themselves to risk, and then evaluate the result. If they don’t scare themselves, they place it in the “acceptable” category. In fact, they may have just been lucky. But the more times they get away with it, the more acceptable the risk becomes.
On the other hand, if they scare themselves they add what they did to the list of things they won’t do again. If they don’t run out of luck, they become an “experienced” pilot. The problem with experience is that she is a hard teacher. She gives the test first, and the lesson comes afterward. Many pilots, and their passengers, never survive to get the lesson.
A Systematic Approach to Risk Management
But even a long list of unacceptable risks doesn’t prepare pilots for risks they’ve never taken or thought of before. What’s needed is a systematic approach to risk management. We already employ a systematic approach to conducting a preflight inspection of an airplane. Just as generations of pilots have been taught since the days of the barnstormers, we very systematically walk around the airplane examining it in great detail—even carefully raising the ailerons to inspect the hinges. But no such procedure is used to consider in advance the pilot’s risk management of the flight.
“…only a very small percentage of accidents are caused by mechanical failure.”
The problem is that only a very small percentage of accidents are caused by a mechanical failure. But a very large percentage of accidents are caused by a failure in risk management on the part of the pilot. The result is that during pre-flight pilots pay very careful attention to things that don’t cause accidents, but spend very little time contemplating the things that do cause accidents.
The reason that pilots spend little time thinking about risk management is we don’t yet have a procedure in place to teach pilots how to do it. As instructors we have earnestly attempted to tell pilots about all the hazards they might face. But we will never be able to think of them all and they wouldn’t be able to remember them.
What pilots need is a tool that they can routinely use to anticipate the risks so that they can be managed. Any systematic, practical procedure to anticipate risks will work, but I suggest the pilots use the PAVE memory aid to “pave” their way to a safe flight.
The letters stand for
- External pressures
A Case Study
Let’s take a look at how PAVE might have worked to help James Jackson analyze the risks associated with his flight:
- Normal piston-engine climb capability
- Fog bank to the west
- Wind from the west
- Commitment to attend a family reunion
As a flight instructor you would probably observe that pilots often overestimate their angle of climb capability. The probability that a pilot would inadvertently wind up in the clouds or stalling the airplane while attempting to out-climb the clouds is high. You would also observe that if a pilot finds themself in this situation, the most important consideration is aircraft control.
You would also note that there was a cross runway and that taking off with a crosswind component might be preferable to attempting to climb over a fog bank.
You might also observe that fog banks often clear up as the day progresses and you might advise delaying the departure to allow the weather to improve.
Risk Management from the First Lesson
So those would probably be your thoughts as a flight instructor. How do you get the new pilot you are training to have the same thoughts?
The answer is that you employ a risk management analysis from the very first lesson. You would teach your learning pilot to identify and manage the risks associated with every flight, and relate their plan to you. From that point on you would no more find it acceptable for them to skip this preflight action than you would for them to go flying without a preflight inspection of the airplane.
With practice, your learning pilot would gain the skill of analyzing the risks and coming up with a mitigation plan for them.
Right now, we are expecting new pilots to learn this on their own after they leave flight training. It clearly is not working. As flight instructors we can and must do better for them.