RMH 1-2

Risk Management Handbook (FAA-H-8083-2A)the pilot’s failure to maintain airplane control during approach. The NTSB report, available here, also contains information about this pilot’s decision-making and risk management. 11779 Many incidents and accidents occur as a result of poor risk management. The following accident review illustrates the importance of risk-based decision-making, as a means to prevent a negative outcome. Risk Management Analysis Using the PAVE Checklist 11780 The accident described above contains risk factors included in the PAVE checklist. As shown in Figure 1-2, the acronym “PAVE” represents hazards that relate to the pilot, the aircraft, the environment, and external pressures. The sample analysis below describes how PAVE items may relate to the accident. 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. Pilot 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. Environment 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. Aircraft 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. External Pressures Figure 1-2. The PAVE checklist. 12855 The pilot reported to air traffic control (ATC) that the vacuum pump failed while in visual meteorological conditions (VMC). As a result, the attitude indicator and directional gyro became inoperative. Rather than divert to an airport while in VMC, the pilot decided to continue toward the destination and into instrument meteorological conditions (IMC). This elevated the risks associated with an “A” hazard because of the inoperative instruments and a “V” hazard because of the IMC. After the vacuum