Risk Management HandbookFAA-H-8083-2A
Front Matter
8 pagesPages i–vii
Risk Management Handbook U.S. Department of Transportation Federal Aviation Administration Flight Standards Service 2022
Preface
This handbook is a tool designed to help recognize and manage risk. It provides a higher level of training to the pilot in command (PIC) who wishes to aspire to a greater understanding of the aviation environment and become a better pilot. This handbook is for pilots of all aircraft from weight-shift control (WSC) to a Piper Cub, a Twin Beechcraft, or a Boeing 747. A pilot's continued interest in building skills is paramount for safe flight and can assist in rising above the challenges which pilots of all backgrounds and experience levels face.
Some basic tools are provided in this handbook for developing a competent evaluation of one’s surroundings that allows for assessing risk and thereby managing it in a positive manner. Risk management is applied by identifying, monitoring, and managing potential components that affect risk thereby allowing the pilot to be better prepared to mitigate risk.
The pilot's work requirements vary depending on the phase of flight. As for a driver transitioning from an interstate onto the city streets of New York, the tasks increase significantly during the landing phase, creating greater risk to the pilot and warranting actions that require greater precision and attention. This handbook attempts to bring forward methods that a pilot can use in managing workload, making the environment safer for the pilot and the passengers.
Occasionally, the word “must” or similar language is used where the desired action is deemed critical. The use of such language is not intended to add to, interpret, or relieve a duty imposed by Title 14 of the Code of Federal Regulations (14 CFR). This handbook is available for download, in PDF format, from www.faa.gov.
This handbook is published by the United States Department of Transportation, Federal Aviation Administration, Airman Testing Standards Branch, P.O. Box 25082, Oklahoma City, OK 73125.
Comments regarding this publication should be emailed to afs630comments@faa.gov.
Introduction
According to the National Transportation Safety Board (NTSB) statistics, in the last 20 years, approximately 85 percent of aviation accidents have been caused by “pilot error.” Many of these accidents are the result of the tendency to focus flight training on the physical aspects of flying the aircraft by teaching the student pilot enough aeronautical knowledge and skill to pass the written and practical tests. In this scenario, risk management is ignored, which can potentially lead to fatal results. The certificated flight instructor (CFI) who integrates risk management into flight training teaches aspiring pilots how to proactively identify safety-related hazards pertaining to the flight and mitigating the associated risks of the identified hazards. A key element of risk decision-making is determining if the risk is justified. The risks involved with flying are quite different from those experienced in daily activities. Managing these risks requires a conscious effort and established standards (or a maximum risk threshold). Pilots who practice effective risk management have predetermined personal minimums and have formed habit patterns and checklists to incorporate them.
If the procedures and techniques described in this handbook are taught and employed, pilots will have tools to identify potential hazards of a flight and successfully mitigate the risks associated with the identified hazards. The goal is to reduce the general aviation accident rate involving poor risk management. Pilots who make a habit of using risk management tools will find their flights considerably more enjoyable and less stressful for themselves and their passengers. In addition, some aircraft insurance companies reduce insurance rates after a pilot completes a formal risk management course.
This Risk Management Handbook makes available recommended tools for identifying hazards and assessing risk in order to conduct the safest flight possible with the least amount of risk. The appendices at the end of this handbook contain checklists and scenarios to aid in risk management consideration, flight planning, and training.
Major Enhancements
This version of the handbook reorganizes risk management concepts in a sequence that pilots use in real world flying.
Chapter 1 explains the difference between risk management exercised by pilots versus a global corporate risk management system, defines the role of the FAA and NTSB, and acknowledges limits in which regulatory compliance can influence safety. This leads to the discussion of personal minimums.
The discussion of personal minimums moved from chapter 8 to chapter 2 and is now the subject of that chapter. Since the handbook cites personal minimums throughout, the initial presentation of this concept comes earlier.
Chapter 2 also briefly discusses the FAA’s WINGS program and has a video link that explains the advantages.
Several FAASTeam video links are included throughout the book, which explain and summarize the concepts presented.
A unified scenario in chapters 3, 4, and 5 shows how to apply risk management concepts before flight begins and explains and demonstrates the use of a flight risk assessment tool (FRAT) in combination with the PAVE checklist.
The discussion of identification of hazards, risk analysis, and risk mitigation has been separated into three chapters (instead of two) to clarify each step and preserve the difference between hazard and risk.
The chapter on hazard identification (chapter 3) discusses pilot attitudes and that discussion continues throughout the book, where relevant.
Chapter 6 begins the discussion of risk as pilots encounter it during actual flying, in terms of threat and error management, with detailed definitions and examples, and an explanation of defenses.
Chapter 7 takes a classic look at what automation is and does, and how pilots should anticipate, act, and verify when using automation. The chapter also includes discussion of flight path management.
Chapter 8 specifically describes ADM training. This chapter focuses on the 3P risk analysis system while in flight and moves more complex models to the appendices. This chapter also contains a real example of naturalistic decision-making and addresses CRM and SRM in more detail.
The appendices describe and analyze accident scenarios and some provide for the reader to make an analysis.
The appendices contain instructions for how readers may use them for maximum benefit.
Specific descriptions of makes and models were removed since a generic description broadens the applicability of concepts presented throughout the book.
Table of Contents
Preface.......................................................................................................................................................................i
Introduction..............................................................................................................................................................ii
Major Enhancements .............................................................................................................................................iii
Chapter 1: Introduction to Risk Management
Introduction .......................................................................................................................................................... 1-1
Safety Management Systems in Aviation............................................................................................................. 1-1
Accident Causality & Responsibility ..................................................................................................................... 1-1
Risk Management Analysis Using the PAVE Checklist ........................................................................................ 1-2
Chapter Summary ................................................................................................................................................ 1-3
Chapter 2: Personal Minimums
Introduction .......................................................................................................................................................... 2-1
Personal Minimums ............................................................................................................................................. 2-1
Step 1—Review Weather Flight Categories ..................................................................................................... 2-1
Step 2—Assess Experience and Comfort Level ............................................................................................... 2-1
Step 3—Consider Other Conditions ................................................................................................................. 2-3
Step 4—Assemble and Evaluate ...................................................................................................................... 2-4
Step 5—Adjust for Specific Conditions ............................................................................................................. 2-5
Step 6—Stick to the Plan .................................................................................................................................. 2-5
Using the FAA WINGS Program for Risk Mitigation & Safety .............................................................................. 2-5
Chapter Summary ................................................................................................................................................ 2-6
Chapter 3: Identifying Hazards & Associated Risks
Introduction .......................................................................................................................................................... 3-1
Hazard Exposure .............................................................................................................................................. 3-1
Why Hazards Result in Aviation Accidents .......................................................................................................... 3-1
Understanding the Risks Posed by Hazards .................................................................................................... 3-2
Leading Accident Causes .................................................................................................................................... 3-3
Identifying Hazards ........................................................................................................................................... 3-4
Using the PAVE Checklist to Identify Hazards ..................................................................................................... 3-4
Pilot Hazards .................................................................................................................................................... 3-4
Aeromedical .................................................................................................................................................. 3-5
Aircraft Hazards ................................................................................................................................................ 3-6
Performance .................................................................................................................................................. 3-6
Equipage ....................................................................................................................................................... 3-6
Environmental Hazards .................................................................................................................................... 3-7
Weather ......................................................................................................................................................... 3-7
Terrain ........................................................................................................................................................... 3-7
Facilities ........................................................................................................................................................ 3-7
Airspace, Air Traffic Control, and Other Aircraft ............................................................................................. 3-8
Night Operations ........................................................................................................................................... 3-8
External Pressure Hazards ............................................................................................................................... 3-8
Hazard Combinations .......................................................................................................................................... 3-8
Hazards and Associated Risks ............................................................................................................................ 3-9
Using a Flight Risk Assessment Tool (FRAT) ................................................................................................. 3-10
Numerical FRATs ......................................................................................................................................... 3-10
Narrative FRATs .......................................................................................................................................... 3-11
Case Study ........................................................................................................................................................ 3-11
Background and Setting ................................................................................................................................. 3-11
Data ................................................................................................................................................................ 3-13
Pilot and Passengers .................................................................................................................................. 3-13
Aircraft ......................................................................................................................................................... 3-13
Environment ................................................................................................................................................ 3-14
Hazard Identification and Risk Analysis .......................................................................................................... 3-14
Pilot ............................................................................................................................................................. 3-14
Aircraft ......................................................................................................................................................... 3-14
Environment ................................................................................................................................................ 3-15
External Pressures ...................................................................................................................................... 3-15
Chapter Summary .............................................................................................................................................. 3-15
Chapter 4: Assessing Risk
Introduction .......................................................................................................................................................... 4-1
Risk Assessment Components ......................................................................................................................... 4-1
Risk Likelihood .............................................................................................................................................. 4-1
Risk Severity ................................................................................................................................................. 4-1
Using a Risk Assessment Matrix.......................................................................................................................... 4-2
Matrix Errors ..................................................................................................................................................... 4-2
Accuracy........................................................................................................................................................ 4-2
Skewing ......................................................................................................................................................... 4-2
Obsolescence................................................................................................................................................ 4-2
Case Study .......................................................................................................................................................... 4-3
Risk Assessment Analysis ................................................................................................................................ 4-3
Pilot ............................................................................................................................................................... 4-3
Aircraft ........................................................................................................................................................... 4-3
Environment .................................................................................................................................................. 4-3
Chapter Summary ................................................................................................................................................ 4-5
Chapter 5: Mitigating Risk
Introduction .......................................................................................................................................................... 5-1
Preflight Risk Mitigation Strategies ...................................................................................................................... 5-1
Mitigating Pilot Risks ........................................................................................................................................ 5-1
Mitigating Aircraft Risks .................................................................................................................................... 5-1
Mitigating Environmental Risks ........................................................................................................................ 5-2
Circumnavigate the Hazard ........................................................................................................................... 5-2
Go Above or Below the Hazard ..................................................................................................................... 5-2
Change Departure Time or Date ................................................................................................................... 5-2
Cancel the Flight ........................................................................................................................................... 5-2
Mitigating External Pressure Risks ................................................................................................................... 5-2
Local Versus Transportation Flights .............................................................................................................. 5-2
Personal Versus Business Flights ................................................................................................................. 5-2
Case Study .......................................................................................................................................................... 5-2
Risk Mitigation Analysis .................................................................................................................................... 5-2
Balanced Approach to Risk Management ............................................................................................................ 5-4
Chapter Summary ................................................................................................................................................ 5-5
Chapter 6: Threat and Error Management
Introduction .......................................................................................................................................................... 6-1
Threats ................................................................................................................................................................. 6-1
What is an Error? ................................................................................................................................................. 6-1
Causes of Errors ............................................................................................................................................... 6-1
Insufficient Training & Experience ................................................................................................................. 6-1
Inadequate Flight Planning or Preparation .................................................................................................... 6-2
Physiological Effects ..................................................................................................................................... 6-2
Psychological Effects .................................................................................................................................... 6-2
What is an Undesired Aircraft State? ................................................................................................................... 6-3
Defenses against Threats, Errors, and Undesired Aircraft States ....................................................................... 6-3
Defenses Provided to the Pilot or Crew ............................................................................................................ 6-3
Checklists, Standard Operating Procedures, and Best Practices ................................................................. 6-3
Utilizing a Second Pilot or Person ................................................................................................................. 6-3
External Resources ....................................................................................................................................... 6-3
Defenses Provided by the Pilot or Crew ........................................................................................................... 6-4
Clear Communication and Briefings .............................................................................................................. 6-4
Effective Situational Awareness .................................................................................................................... 6-4
Planning for What Comes Next ..................................................................................................................... 6-4
Time Management......................................................................................................................................... 6-4
Teamwork ...................................................................................................................................................... 6-4
Automation Management .............................................................................................................................. 6-4
Flying Skills (The Last Resort) ...................................................................................................................... 6-4
Chapter Summary ................................................................................................................................................ 6-5
Chapter 7: Automation & Flight Path Management
Introduction .......................................................................................................................................................... 7-1
Reliance on Automation ....................................................................................................................................... 7-2
Balancing Automated & Manual Flight ................................................................................................................. 7-2
Interacting with Automation .................................................................................................................................. 7-2
Failure to Anticipate, Act, & Verify ........................................................................................................................ 7-3
Integrated Flight Path Automation Systems ......................................................................................................... 7-3
Chapter Summary ................................................................................................................................................ 7-4
Chapter 8: Aeronautical Decision-Making in Flight
Introduction .......................................................................................................................................................... 8-1
ADM Background ................................................................................................................................................. 8-1
Analytical Decision-Making .................................................................................................................................. 8-1
Naturalistic Decision-Making................................................................................................................................ 8-3
Single-Pilot Resource Management .................................................................................................................... 8-3
Chapter Summary ................................................................................................................................................ 8-4
Appendix Introduction
Scope ..................................................................................................................................................................AI-1
How to Use .........................................................................................................................................................AI-1
Using Appendices as a Workbook ......................................................................................................................AI-1
Appendix A: Risk Management Training
Integrating Risk Management Training and Other Training Requirements ..........................................................A-1
Appendix B: Risk Management Tools
Risk Assessment Tools Identifying, Assessing, & Mitigating Risk ........................................................................B-1
Risk Identification Tools ....................................................................................................................................B-1
Additional Risk Assessment Tools .......................................................................................................................B-3
Risk Mitigation Tools .........................................................................................................................................B-3
Appendix C: Accident Case Studies
General Information ............................................................................................................................................ C-1
Accident Profile 1: Fatal Accident in a Single-Engine Airplane with a Piston Engine ......................................... C-1
NTSB Probable Cause .................................................................................................................................... C-1
NTSB Factual Summary Excerpts (edited) ...................................................................................................... C-1
Risk Identification, Assessment, and Mitigation ............................................................................................... C-1
Accident Profile 2: Fatal Accident, Turboprop-Powered, Transportation ............................................................ C-2
NTSB Probable Cause .................................................................................................................................... C-2
NTSB Factual Summary Excerpts (edited) ...................................................................................................... C-2
Risk Identification, Assessment, and Mitigation ............................................................................................... C-3
Accident Profile 3: Fatal Accident, Helicopter, Personal Flight ........................................................................... C-3
NTSB Probable Cause .................................................................................................................................... C-3
NTSB Factual Summary Excerpts (edited) ...................................................................................................... C-3
Risk Identification, Assessment, and Mitigation ............................................................................................... C-4
Accident Profile 4: Fatal Turbojet-Powered Airplane Accident ............................................................................ C-4
NTSB Probable Cause .................................................................................................................................... C-4
NTSB Factual Summary Excerpts (edited) ...................................................................................................... C-4
Risk Identification, Assessment, and Mitigation ............................................................................................... C-4
Appendix D: Risk Management Exercises
Four Scenarios.................................................................................................................................................... D-1
Scenario 1: Recreational Aviation .................................................................................................................... D-1
Scenario 2: Turboprop-Powered, Personal Transportation ............................................................................. D-2
Scenario 3: Turbine Helicopter ........................................................................................................................ D-2
Scenario 4: Turbojet-Powered Airplane ........................................................................................................... D-3
Glossary ...............................................................................................................................................................G-1
Index ...................................................................................................................................................................... I-1