(We originally wrote this article for the
National Association of Flight Instructors)
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.
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
James Jackson 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 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.
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:
- Not instrument rated
- 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.
P.A.V.E. How a minimum amount of training/planning can have an extraordinary impact for the better. Thanks for the wisdom!
Hola soy Ressly H. Romero L. me gusta mucho la aviacion pero aqui en Nicaragua no se puede estudiar aviacion con costo hay avione. Saludes a todos
Actually AOPA offers just such an interactive risk assessment tool for every flight a pilot makes, if he chooses to use it. It’ on their web site.
Having an instrument rating can be a plus but it is not a license to ignore weather! Fatal crashes for the most part are due to wrong headed Pilot decision making. As the presentation indicated the highest percent of fatalities is not a fault with mechanical, electrical or electronic device or equipment… It comes down to ” What the Hell was he/ she thinking”? Mother Nature can be a Cruel Bit_H with no mercy!! Be HUMBLE & Live to fly another day!
Nice pesentation, Folks. I would suggest this, based on my lifes experiences with actual situations, ….NEVER, NEVER, NEVER entrust your life and the lives of your passengers with any mechanical, electrical or electronic device or equipment…period !!!
Unfortunately, I don’t have wings growing out of my back so I have to entrust my life to a combination of “mechanical, electrical, and electronic equipment” every time I leave the ground. Sure, no single piece of equipment failure should be trusted blindly, but let’s not kid ourselves. Our lives depend on this equipment functioning. That said, looking at accident reports, however, it seems that the most commonly malfunctioning piece of equipment onboard is the one between the pilot’s ears. It’s the “primary instrument” for aeronautical decision making in all phases of flight, and it seems fails with disastrous consequences. I think that is more the issue PAVE attempts to address more than pilots over relying on systems. Thoughts?
I am 100% with you on PAVE’s risk management. As instructors we must ask or allow our students to make the Aeronautical Decision based on those risks in order to complete the process. Until the student is taught the levels of risk, the danger signs (such as a must go trip), their own human traits (leadership traits), and how all these human factors can result in a bad aeronautical decision, we will continue to make bad decisions.
Owner – Air Venture Flight Center
Personally I think the “risk management” portion needs a “risk” scale and an assessment as part of pre-flight.
For example, in your sample above, the fog bank should add a risk factor of, let’s say, 4 on a scale of 1-10.
Knowing you’re going to try a steeper angle of climb thatn normal…another 3 and so forth.
Then have a “risk scale” of something 0-2 Good. 3-6. Be cautious. 7-8. Moderate to high risk. 9-10 EXTREME RISK. In this case, if the pilot realized he was putting himself in the “Moderate to high risk” range BEFORE he took off – maybe his actions would’ve been different.
What I’m getting at is that currently there seems to be a “digital” type “go/no go” attitude with nothing in between in terms of risk assesment. As long as a pilot pre-flights and thinks he’s good to go…. it’s a “go”. There isn’t an analog approach of “ranges”. If there were, perhaps it would at least make pilots more aware of the risk they are facing.
Just my 2cents worth.
More pictures would really help. It sounds strange, but seeing situations is a lot different than reading about them in a PAVE training scenario or more sobering, an NTSB report. For any of you CFI’s out there, next time you’re giving that thunderstorm a wide berth, asking for a deviation for weather, or looking at that questionable pass that you decide to avoid, take a picture with that iphone of what you’re seeing outside/on the panel. Better yet, take a video, post it, and subject it to a collective PAVE analysis from the community. The result would be a database of scenarios and discussions featuring a quantum leap in realism from the narratives we read.
A lot of us train for our instrument rating by riding around with a hood on only to find out after we pass our check-ride (i haven’t taken it yet btw), that we have little experience in real world weather decision making because we haven’t actually “seen it” (radar, windshield, xm, atc, etc). We’ve only read about it, been told what it’s like, or worked a theoretical problem with very limited “visuals”. Hoods are one thing, but popping in and out of the clouds seeing a thunderstorm at your 2 o’clock and asking for a deviation seems to be much more the real world in GA. Ironically, that time your scan picks up that towering thunderstorm in the windshield, and you ask atc for the deviation while you’re 1,000 ft above an OVC layer doesn’t count a lick toward your instr rating (as I understand it) as you aren’t restricted to flight “solely by reference to the instruments”. But it would scare the heck of me if I had never “seen it” before – rating or not. I feel lucky my CFII insists on quite a bit of actual, but he certainly can’t “show” me all the scenarios I’ll run into. However, maybe if we all collectively start using the camera on the back of that ipad in our lap, we can help our fellow GA pilots “see it” before they actually put themselves “in it”.
Wow had your LSA Comp. Kit , GREAT , Doing Dual with CFI now . Thanks for the super good course !!!!!!!!!!!