Pilot's Handbook of Aeronautical Knowledge (Federal Aviation Administration)
Page 10
Passengers can also be pilots. If no one is designated as pilot in command (PIC) and unplanned circumstances arise, the decision-making styles of several self-confident pilots may come into conflict.
Pilots also need to understand that non-pilots may not understand the level of risk involved in flight. There is an element of risk in every flight. That is why SRM calls it risk management, not risk elimination. While a pilot may feel comfortable with the risk present in a night IFR flight, the passengers may not. A pilot employing SRM should ensure the passengers are involved in the decision-making and given tasks and duties to keep them busy and involved. If, upon a factual description of the risks present, the passengers decide to buy an airline ticket or rent a car, then a good decision has generally been made. This discussion also allows the pilot to move past what he or she thinks the passengers want to do and find out what they actually want to do. This removes self-induced pressure from the pilot.
The Programming
The advanced avionics aircraft adds an entirely new dimension to the way GA aircraft are flown. The electronic instrument displays, GPS, and autopilot reduce pilot workload and increase pilot situational awareness. While programming and operation of these devices are fairly simple and straightforward, unlike the analog instruments they replace, they tend to capture the pilot’s attention and hold it for long periods of time. To avoid this phenomenon, the pilot should plan in advance when and where the programming for approaches, route changes, and airport information gathering should be accomplished, as well as times it should not. Pilot familiarity with the equipment, the route, the local ATC environment, and personal capabilities vis-à-vis the automation should drive when, where, and how the automation is programmed and used.
The pilot should also consider what his or her capabilities are in response to last minute changes of the approach (and the reprogramming required) and ability to make large-scale changes (a reroute for instance) while hand flying the aircraft. Since formats are not standardized, simply moving from one manufacturer’s equipment to another should give the pilot pause and require more conservative planning and decisions.
The SRM process is simple. At least five times before and during the flight, the pilot should review and consider the “Plan, the Plane, the Pilot, the Passengers, and the Programming” and make the appropriate decision required by the current situation. It is often said that failure to make a decision is a decision. Under SRM and the 5 Ps, even the decision to make no changes to the current plan is made through a careful consideration of all the risk factors present.
Perceive, Process, Perform (3P) Model
The Perceive, Process, Perform (3P) model for ADM offers a simple, practical, and systematic approach that can be used during all phases of flight. To use it, the pilot will:
• Perceive the given set of circumstances for a flight
• Process by evaluating their impact on flight safety
• Perform by implementing the best course of action
Use the Perceive, Process, Perform, and Evaluate method as a continuous model for every aeronautical decision that you make. Although human beings will inevitably make mistakes, anything that you can do to recognize and minimize potential threats to your safety will make you a better pilot.
Depending upon the nature of the activity and the time available, risk management processing can take place in any of three timeframes. [Figure 2-10] Most flight training activities take place in the “time-critical” timeframe for risk management. The six steps of risk management can be combined into an easy-to-remember 3P model for practical risk management: Perceive, Process, Perform with the PAVE, CARE and TEAM checklists. Pilots can help perceive hazards by using the PAVE checklist of: Pilot, Aircraft, enVironment, and External pressures. They can process hazards by using the CARE checklist of: Consequences, Alternatives, Reality, External factors. Finally, pilots can perform risk management by using the TEAM choice list of: Transfer, Eliminate, Accept, or Mitigate.
PAVE Checklist: Identify Hazards and Personal Minimums
In the first step, the goal is to develop situational awareness by perceiving hazards, which are present events, objects, or circumstances that could contribute to an undesired future event. In this step, the pilot will systematically identify and list hazards associated with all aspects of the flight: Pilot, Aircraft, enVironment, and External pressures, which makes up the PAVE checklist. [Figure 2-11] For each element, ask “what could hurt me, my passengers, or my aircraft?” All four elements combine and interact to create a unique situation for any flight. Pay special attention to the pilot-aircraft combination, and consider whether the combined “pilot-aircraft team” is capable of the mission you want to fly. For example, you may be a very experienced and proficient pilot, but your weather flying ability is still limited if you are flying a 1970s-model aircraft with no weather avoidance gear. On the other hand, you may have a new technically advanced aircraft with moving map GPS, weather datalink, and autopilot—but if you do not have much weather flying experience or practice in using this kind of equipment, you cannot rely on the airplane’s capability to compensate for your own lack of experience.
Figure 2-10. Risk management processing can take place in any of three timeframes.
CARE Checklist: Review Hazards and Evaluate Risks
In the second step, the goal is to process this information to determine whether the identified hazards constitute risk, which is defined as the future impact of a hazard that is not controlled or eliminated. The degree of risk posed by a given hazard can be measured in terms of exposure (number of people or resources affected), severity (extent of possible loss), and probability (the likelihood that a hazard will cause a loss). The goal is to evaluate their impact on the safety of your flight, and consider “why must I CARE about these circumstances?”
For each hazard that you perceived in step one, process by using the CARE checklist of: Consequences, Alternatives, Reality, External factors. [Figure 2-12] For example, let’s evaluate a night flight to attend a business meeting:
Consequences—departing after a full workday creates fatigue and pressure
Alternatives—delay until morning; reschedule meeting; drive
Reality—dangers and distractions of fatigue could lead to an accident
External pressures—business meeting at destination might influence me
A good rule of thumb for the processing phase: if you find yourself saying that it will “probably” be okay, it is definitely time for a solid reality check. If you are worried about missing a meeting, be realistic about how that pressure will affect not just your initial go/no-go decision, but also your inflight decisions to continue the flight or divert.
TEAM Checklist: Choose and Implement Risk Controls
Once you have perceived a hazard (step one) and processed its impact on flight safety (step two), it is time to move to the third step, perform. Perform risk management by using the TEAM checklist of: Transfer, Eliminate, Accept, Mitigate to deal with each factor. [Figure 2-13]
Transfer—Should this risk decision be transferred to someone else (e.g., do you need to consult the chief flight instructor?)
Eliminate—Is there a way to eliminate the hazard?
Accept—Do the benefits of accepting risk outweigh the costs?
Mitigate—What can you do to mitigate the risk?
The goal is to perform by taking action to eliminate hazards or mitigate risk, and then continuously evaluate the outcome of this action. With the example of low ceilings at destination, for instance, the pilot can perform good ADM by selecting a suitable alternate, knowing where to find good weather, and carrying sufficient fuel to reach it. This course of action would mitigate the risk. The pilot also has the option to eliminate it entirely by waiting for better weather.
Figure 2-11. A real-world example of how the 3P model guides decisions on a cross-country trip using the PAVE checklist.
Figure 2-12. A real-world examples of how the 3P model guides
decisions on a cross-country trip using the CARE checklist.
Once the pilot has completed the 3P decision process and selected a course of action, the process begins anew because now the set of circumstances brought about by the course of action requires analysis. The decision-making process is a continuous loop of perceiving, processing, and performing. With practice and consistent use, running through the 3P cycle can become a habit that is as smooth, continuous, and automatic as a well-honed instrument scan. This basic set of practical risk management tools can be used to improve risk management.
Your mental willingness to follow through on safe decisions, especially those that require delay or diversion is critical. You can bulk up your mental muscles by:
• Using personal minimums checklist to make some decisions in advance of the flight. To develop a good personal minimums checklist, you need to assess your abilities and capabilities in a non-flying environment, when there is no pressure to make a specific trip. Once developed, a personal minimums checklist will give you a clear and concise reference point for making your go/no-go or continue/discontinue decisions.
• In addition to having personal minimums, some pilots also like to use a preflight risk assessment checklist to help with the ADM and risk management processes. This kind of form assigns numbers to certain risks and situations, which can make it easier to see when a particular flight involves a higher level of risk
• Develop a list of good alternatives during your processing phase. In marginal weather, for instance, you might mitigate the risk by identifying a reasonable alternative airport for every 25–30 nautical mile segment of your route.
Figure 2-13. A real-world example of how the 3P model guides decisions on a cross-country trip using the TEAM checklist.
• Preflight your passengers by preparing them for the possibility of delay and diversion, and involve them in your evaluation process.
• Another important tool—overlooked by many pilots—is a good post-flight analysis. When you have safely secured the airplane, take the time to review and analyze the flight as objectively as you can. Mistakes and judgment errors are inevitable; the most important thing is for you to recognize, analyze, and learn from them before your next flight.
The DECIDE Model
Using the acronym “DECIDE,” the six-step process DECIDE Model is another continuous loop process that provides the pilot with a logical way of making decisions. [Figure 2-14] DECIDE means to Detect, Estimate, Choose a course of action, Identify solutions, Do the necessary actions, and Evaluate the effects of the actions.
First, consider a recent accident involving a Piper Apache (PA-23). The aircraft was substantially damaged during impact with terrain at a local airport in Alabama. The certificated airline transport pilot (ATP) received minor injuries and the certificated private pilot was not injured. The private pilot was receiving a checkride from the ATP (who was also a designated examiner) for a commercial pilot certificate with a multi-engine rating. After performing airwork at altitude, they returned to the airport and the private pilot performed a single-engine approach to a full stop landing. He then taxied back for takeoff, performed a short field takeoff, and then joined the traffic pattern to return for another landing. During the approach for the second landing, the ATP simulated a right engine failure by reducing power on the right engine to zero thrust. This caused the aircraft to yaw right.
The procedure to identify the failed engine is a two-step process. First, adjust the power to the maximum controllable level on both engines. Because the left engine is the only engine delivering thrust, the yaw increases to the right, which necessitates application of additional left rudder application.
Figure 2-14. The DECIDE model has been recognized worldwide. Its application is illustrated in column A while automatic/naturalistic decision-making is shown in column B.
The failed engine is the side that requires no rudder pressure, in this case the right engine. Second, having identified the failed right engine, the procedure is to feather the right engine and adjust power to maintain descent angle to a landing.
However, in this case the pilot feathered the left engine because he assumed the engine failure was a left engine failure. During twin-engine training, the left engine out is emphasized more than the right engine because the left engine on most light twins is the critical engine. This is due to multiengine airplanes being subject to P-factor, as are single-engine airplanes. The descending propeller blade of each engine will produce greater thrust than the ascending blade when the airplane is operated under power and at positive angles of attack. The descending propeller blade of the right engine is also a greater distance from the center of gravity, and therefore has a longer moment arm than the descending propeller blade of the left engine. As a result, failure of the left engine will result in the most asymmetrical thrust (adverse yaw) because the right engine will be providing the remaining thrust. Many twins are designed with a counter-rotating right engine. With this design, the degree of asymmetrical thrust is the same with either engine inoperative. Neither engine is more critical than the other.
Since the pilot never executed the first step of identifying which engine failed, he feathered the left engine and set the right engine at zero thrust. This essentially restricted the aircraft to a controlled glide. Upon realizing that he was not going to make the runway, the pilot increased power to both engines causing an enormous yaw to the left (the left propeller was feathered) whereupon the aircraft started to turn left. In desperation, the instructor closed both throttles and the aircraft hit the ground and was substantially damaged.
This case is interesting because it highlights two particular issues. First, taking action without forethought can be just as dangerous as taking no action at all. In this case, the pilot’s actions were incorrect; yet, there was sufficient time to take the necessary steps to analyze the simulated emergency. The second and more subtle issue is that decisions made under pressure are sometimes executed based upon limited experience and the actions taken may be incorrect, incomplete, or insufficient to handle the situation.
Detect (the Problem)
Problem detection is the first step in the decision-making process. It begins with recognizing a change occurred or an expected change did not occur. A problem is perceived first by the senses and then it is distinguished through insight and experience. These same abilities, as well as an objective analysis of all available information, are used to determine the nature and severity of the problem. One critical error made during the decision-making process is incorrectly detecting the problem. In the previous example, the change that occurred was a yaw.
Estimate (the Need To React)
In the engine-out example, the aircraft yawed right, the pilot was on final approach, and the problem warranted a prompt solution. In many cases, overreaction and fixation excludes a safe outcome. For example, what if the cabin door of a Mooney suddenly opened in flight while the aircraft climbed through 1,500 feet on a clear sunny day? The sudden opening would be alarming, but the perceived hazard the open door presents is quickly and effectively assessed as minor. In fact, the door’s opening would not impact safe flight and can almost be disregarded. Most likely, a pilot would return to the airport to secure the door after landing.
The pilot flying on a clear day faced with this minor problem may rank the open cabin door as a low risk. What about the pilot on an IFR climb out in IMC conditions with light intermittent turbulence in rain who is receiving an amended clearance from ATC? The open cabin door now becomes a higher risk factor. The problem has not changed, but the perception of risk a pilot assigns it changes because of the multitude of ongoing tasks and the environment. Experience, discipline, awareness, and knowledge influences how a pilot ranks a problem.
Choose (a Course of Action)
After the problem has been identified and its impact estimated, the pilot must determine the desirable outcome and choose a course of action. In the case of the multiengine pilot given the s
imulated failed engine, the desired objective is to safely land the airplane.
Identify (Solutions)
The pilot formulates a plan that will take him or her to the objective. Sometimes, there may be only one course of action available. In the case of the engine failure already at 500 feet or below, the pilot solves the problem by identifying one or more solutions that lead to a successful outcome. It is important for the pilot not to become fixated on the process to the exclusion of making a decision.
Do (the Necessary Actions)
Once pathways to resolution are identified, the pilot selects the most suitable one for the situation. The multiengine pilot given the simulated failed engine must now safely land the aircraft.
Evaluate (the Effect of the Action)
Finally, after implementing a solution, evaluate the decision to see if it was correct. If the action taken does not provide the desired results, the process may have to be repeated.