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 seeit 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
Using PAVE helps to identify risk before departure and assists the pilot’s decision-making process. 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
Using PAVE helps to identify risk before departure and assists the pilot’s decision-making process. 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 unique to that individual pilot’s current level of
experienceand proficiency.One of the most important concepts that safe
pilotsunderstand is the difference between what is “legal” in termsof the
regulations, and what is “smart” or “safe” in terms of
pilot experience and proficiency.
PILOT:
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.
AIRCRAFT:
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.
EnVironment:
The environment encompasses many elements that are not pilot or airplane related, including such factors as weather,
AIRCRAFT:
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.
EnVironment:
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.
External Pressures:
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
External Pressures:
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
P = Pilot in command
P = Pilot in command
The pilot in command is one
of the risk factors in a flight. The pilot must ask, “Am I ready forthis trip?”
in terms of experience, currency, physical, and emotional condition
The Pilot’s Health
The Pilot’s Health
One
of the best ways pilots can mitigate risk is a selfevaluation to ensure they
are in good health. A standardizedmethod used in evaluating health employs the
IMSAFEchecklist. 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.
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Figure . The highest risk for
the pilot is self, and requires special introspective analysis.
While the regulations list medical conditions that require grounding, stress is not among them. The pilot should
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. Acertain 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. . Factors referred to as stressors can
affect decision-making skills and increase a
pilot’s
risk of error in the flight deck. 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.
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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?
• Can this aircraft use the runways available for the trip with an adequate margin of safety under the conditions
• 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
•
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., 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.
• 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) and other easily obtainable data to minimize chances of an inflight collision with terrain or obstacles.
• Use maximum elevation figures (MEF) and other easily obtainable data to minimize chances of an inflight collision with terrain or obstacles.
Figure . The pilot can easily assess elevations at a glance
bysimply 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
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)? 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
•
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 . 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 notreplace the regulatory
requirement of carrying flashlights.
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. 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.
Figure . 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 w 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.
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’sarrival
• 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-homeitis,”“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.
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
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 decisionmaking 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.
ASSESSING RISK
Introduction
ASSESSING RISK
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.
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:
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
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
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. It assesses
Two items: the likelihood of an event occurring and the consequence of that
event.Quantifying Risk Using a Risk Matrix
Figure . A sample risk
assessment matrix a pilot can use to differentiate between low-risk and
high-risk flights.
Likelihood of an 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
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.
Melis there is coherence in your work that is something I appreciate, I didn’t find it in most of the papers I read. No negative comment about the media they are well displayed and facilitate the understanding. But I believe that this work could be a little shorter except that everything is fine.
YanıtlaSilIt contains very useful information although too long and made clearer supported by images.
YanıtlaSilThis topic was very interesting. You explained the issue from every angle. I learned many things from this article like PAVE and risk matrix. Especially pictures you used was very instructive.Thank you sister. :)
YanıtlaSilTrue. Pilots seldom learn from mistakes unless they debrief, which is.not likely the case at airlines where the work rhythm account for a very hectic life. We should not forget that regulations are often made and published only after a disaster or incident. Undeniably, health is paramount and has been stressed lately at Lufthansa with refined medical pre and post–checks particularly after this year's deadly Germanwings crash. Interestingly, you could have mentioned the Swiss Cheese model for mitigation of risks.
YanıtlaSil