Article appeared in Flying Magazine March, 2014 by John King – There is nothing that will make you think about changing your ways in flying like an accident. After Martha and I had our accident, we urgently wanted to avoid another one—but we didn’t intuitively know what to do differently. We did know that somehow our attitudes about risk-taking had to change. It was pretty clear that we should quit doing “stupid stuff” … but it never seems that stupid when you are doing it.
As “experienced” pilots we had begun accumulating a long list of things we weren’t going to do anymore. Each scary experience gave us a new lesson. After our accident we felt especially lucky to have survived that particular test in order to get the lesson. The problem was we were learning a lot of individual lessons, but we were putting ourselves at risk to learn each new lesson. And even a super-long list of things we weren’t going to do any more didn’t prepare us for something we hadn’t thought of or tried yet.
Our method clearly was not a good one. Plus, as ground instructors on a regular circuit we were meeting other pilots who were learning lessons the same way, and too many of those pilots, and their passengers, weren’t surviving the test in order to get the lesson. The death of one of these pilots in particular started us thinking and talking a lot about what could be done to improve not only our own risk management but that of all general aviation pilots.
A necessary first step, in our view, was for the general aviation community to start admitting that there are risks associated with flying. Our philosophy was that if we deny the risks of flying, we probably won’t do a very good job of managing them.
We had for too long been telling what Martha and I call “The Big Lie.” “The Big Lie” is one that you have been telling so long and so often, that you have come to believe it yourself. The big lie in general aviation is, “The most dangerous part of the trip was the drive to the airport.” It is a great saying, and it is true for flying on the airlines. But sadly, it isn’t even close to being true for general aviation. You are seven times more likely per mile to be involved in a fatality in a GA airplane than you are in a car. (Compare the fatal accident rate per mile of cars from the National Highway Transportation Safety Administration to the fatal accident rate per hour for airplanes from the National Transportation Safety Board, and assume an average speed of 150 miles per hour for airplanes.)
In March of 2001 Flying Magazine courageously provided us a venue to start a national dialog on this controversial subject with an interview by Lane Wallace entitled “Battling the Big Lie.” This prompted a letter from Jim Lauerman of AVEMCO Insurance saying basically, “OK, wise-guys, you’ve identified the problem. What are you going to do about it?” As a result of Jim’s encouragement we decided we should work to develop risk management tools that pilots would find practical and useful.
The important part was to use an acceptable vocabulary and frame things in a way that was insightful and new to pilots. After all, as the Greek philosopher Epictetus observed, “It is impossible for a man to learn what he thinks he already knows.”
The first tool we came up with, along with folks from The Ohio State University and the FAA, was what we called the PAVE checklist. The idea was to help give pilots a way to systematically identify the risks associated with a flight by putting them into the categories of Pilot, Aircraft, enVironment, and External pressures. Clearly, we had to strain to make an acronym of this. Using the third letter of “environment” instead of the first letter is a little strange, and “External pressures” might just have well been called “pressures” except we needed an “E” to make a pronounceable word. “External pressures” refers to those things, like the pressure to make a schedule or to meet someone at the destination, that tend to make a pilot ignore all the other risk factors of the flight. A pilot’s hardwired tendency to complete whatever goal they have set for themselves belongs in that category. The idea behind the word “external” is that these pressures originate from things mostly external to the flight.
Many pilots look at PAVE and the other acronyms that we developed and think, “Give me a break. Do you expect me to say ‘PAVE’ out loud to myself every time I go flying?” The answer is, “No, we don’t.” And I’ll let you in on a little secret. We don’t say it out loud every time either. What then is the benefit of the acronym?
The process of learning about PAVE makes you think about the risks of a flight and it is a useful tool to use when you are learning the process of identifying risks. After that, when you see a risk, you think things like, “I am extremely tired tonight. That is a pilot risk factor and I need to figure out some way to mitigate that risk, like departing in the morning instead of tonight, or taking another pilot with me.” So learning PAVE actually helps you identify risks and makes you more alert to them when they occur—even if you don’t go around muttering “PAVE” to yourself.
The same thing goes for the CARE situational awareness scan. CARE stands for Consequences, Alternatives, Reality, and External pressures. The idea is that as soon as you get airborne all the risk factors of a flight start changing.
The pilot is getting progressively more fatigued.
The aircraft is getting lower on fuel.
The environment is changing. You are flying over changing terrain and in changing weather, and it is getting later in the day and closer to darkness.
Realty changes, but pilots often go into denial when the changes interfere with their plans. That’s why we had our accident. The “R” in care reminds you to deal with reality instead of denying it.
And finally, the external pressures become more intense the closer you get to your destination. It is much harder to land short of the destination than it would have been to not depart in the first place.
The thought behind the CARE acronym is to remember to be aware of your new situation when those changes take place. Once again, we don’t keep muttering the word “CARE” during a flight, but CARE does come to mind when changes occur. For instance, when weather changes begin to make an alternative go away, the fact that you have learned the CARE acronym reminds you of the importance of identifying a new alternative or landing early.
There is one acronym that we do actually think about and use on every flight—and that is the CHORRD checklist. We use it in the run-up area before takeoff. CHORRD stands for Conditions, Hazards, Operational changes required, Runway required and available, Return procedure, and our Departure route and altitudes. It is a situational awareness tool that we use to help us remember to take a final look, just before takeoff, at current conditions and what will happen next. It provides one last opportunity to manage the risks of takeoff and departure.
Now does all of this make any difference? Pilots have told us it does. Pilots have told us they and their passengers are alive today because they used these tools. But in order for it to work, risk identification, assessment and mitigation have to be a habit, and they will work best as a habit that is learned, and practiced, from the very first flight lesson on.
If risk management is not a habit that is developed during the process of flight training, pilots are left to develop it on their own afterwards. That’s what pilots have had to do in the past, and it hasn’t worked all that well. During the process of flight instruction, instructors are doing a pretty good job of managing the risks of flight, but they are not doing as good a job yet of passing those skills along. As soon as a pilot leaves flight instruction and goes out on their own, the accident rate jumps by almost 50%. We can do a lot better than that.
very good article and the importance of mitigatioin of decisions.
Hello John and Martha,
I have been called a maintenance zealot. My experience with turbine aircraft carried over to maintenance of a Cessna 182. Some components have no time or cycle limitations calling for replacement or overhaul. Other components have only suggested repair or overhaul. In in other words fly it until you break it. That failure can happen exactly when you don’t want it to happen. Risk management entails researching and setting your own limits before overhaul or replacement such as: alternators, vacuum gages, magnetos and tires.
Hi John and Martha,
Another great article, thanks for sharing and also inspiring me a bit more while I take your FIRC for 2021. I would like to add that I always start with the PAVE checklist prior to meeting my students at the field and its funny too, sometimes I will purposely not ask them if they are IMSAFE or PAVE and they will immediately come back with a response like…..”yep I’m good, no medications today”, and that makes me feel good because it shows that I instilled in them (Risk Management) that they need to analyze themselves, the plane and the environment in which they fly. I would like to add that I break down the PAVE checklist a little more with “A” being if the plane is Airworthy with the required documents ….”ARROW” and “TOMATOS AFLAME”, the E for Environment……with doing a good weather briefing and map recon for TFR’s, warning areas, airspace and such. Well enough said, back to the course.
Lou DiVentura CFI
Thanks for checking in Lou! It really is very cool that your students are carrying that Risk Management torch – great work! Enjoy the FIRC, and let us know if you need anything.
There is nothing like having an accident to make you review over and over what you could have done better-if you are fortunate enough to still be alive! I have reviewed the scenario of a prop strike I had with a student and have come up with a lot of remedial training for myself! Thanks for sharing your thoughts.
Hi John and Martha,
Hope all is well, I’m currently taking your FIRC, was just thinking maybe we should change the acronym IMSAFE to something else since the word SAFE means to be free from harm.
Just some thought. BTW I enjoyed your article….After we had our accident.
Lou DiVentura CFI
Great Article John and you hit the nail on the head square in the last paragraph.
As a CFI and also VP of a rather large flying club here in San Diego we always stress risk management to all the member CFIs and how we needed that skill passed on to the membership constantly. Too many times we have had incidents where good risk management could have saved lives, devastated families and hundreds of thousands of dollars.
I am a student pilot and greatly enjoying your Ground School online course, which is extremely well done. Many thanks to Martha and you.
Regarding your accident, did you ever find out why the battery drained after the generator failure, even though you attempted to disable all electrical equipment?
Great article on Risk Management
My aviation partner and I like to read the accidents reported in the NTSB recent reports listed in the magazine , “Aviation Safety”. We then discuss various risk factors that may have affected each flight and then discuss what our actions would be given the same set of circumstances. This has been very helpful when planning our various cross countries.
Hi John & Martha,
I recently purchased your PPL “Get It All” kit, and I watched the free video that comes with it — a risk management video. Interestingly, I mentioned some of what you guys were advocating to a group of GA pilots in a Reddit group, and I got some dissent. It seems that some GA pilots think it’s okay to fly with dodgy instruments and things like that — essentially they were asserting that their experience mitigates the dodgy situation. One even asserted that it was good practice to fly without an AI or DG. When I offered up that on the whole, we GA pilots need to think more like ATPs, they came up with a bevy of reasons why ATPs divert or don’t take off (like they’re flying IFR all the time — they HAVE to divert if something’s wrong). The whole time I was reading their replies I was thinking “I wonder what John & Martha would say to these naysayers.”
I had a conversation about risk management this evening with my CFI after we did some pattern work and practiced stalls this evening. He agreed with the risk management approaches you were advocating, and had a different name for one of them (something he had learned in his Part 141 training I assume). He said it’s a daily struggle for him to try to remain like a student pilot in terms of managing risks, following checklists carefully, not ignoring minor issues, and so on.
After reading through all those Reddit comments, I can see why the GA accident rates are higher than they should be. Lots of people seem to have a cavalier attitude toward risk management, or they’re hyper focused on “their experience”, but as you guys mentioned, experience is kind of a dodgy teacher, and either you aren’t around to learn the lesson after, or you might just be getting lucky.
Anyway, I truly appreciate the focus you’re trying to put on risk management. I’m not the “hair on fire, going mach II” kind of person that tends to be attracted to aviation I think. It took me 20 years to get from “I might want to be a pilot some day” to actually taking lessons, partially because of the risks involved. It’s good to hear from experienced pilots like yourselves who are advocating more sound risk management in general aviation. Let the test pilots take the big risks! 🙂