After we had our accident

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.