RMH 6-2

Risk Management Handbook (FAA-H-8083-2A)may find themselves in an unfamiliar situation that may result in serious errors. Pilots seeking the thrill of an adventure should consider the potential danger from errors that may occur. Inadequate Flight Planning or Preparation 18390 Chapters 3, 4, and 5 of this handbook discuss risk analysis as an important step in the flight planning process. However, the pilot can only conduct a preflight risk analysis based on the information gathered before flight. Inadequate flight planning may leave a pilot in unanticipated conditions and can lead to errors. For example, a pilot dropped off a passenger at the Edward F. Knapp State airport (KMPV) in rural Vermont and expected to refuel for the return trip to White Plains, New York (KHPN). Upon arrival, fuel or other services were not available since it was the weekend. The pilot thought about waiting but decided to fly home after estimating the fuel would be sufficient. The pilot filed a flight plan in the air as visibility started to diminish after departure. Soon after, ATC required a hold as the destination airport had closed for snow removal. The entire region was becoming affected by a snowstorm, and the pilot was running low on fuel. Luckily, after explaining the situation to the controller, the pilot was able to divert to Bridgeport in Connecticut (KBDR), which was the last airport open in the area. Fortunately, the ceiling was just above minimums for the instrument approach, and the pilot was able to land the aircraft in a few inches of snow. Bridgeport closed shortly thereafter for snow removal. Physiological Effects 18391 Some of the items listed on the I’m Safe checklist (illness, medication, stress, alcohol, fatigue) have the potential to cause pilot errors. For example, it may become difficult or impossible for a stressed or fatigued pilot to focus on a situation or task. Not acting when necessary also constitutes an error. 18392 Limitations affect human senses and perception. For example, when will a pilot see another aircraft on a collision course? The avoidance maneuver may depend not only on where the pilot is looking, but also on the pilot’s individual sense of vision combined with all the visual signals received at the same time. Psychological Effects 18393 Psychological effects include stress, emotion, expectation bias, and the effects of personality. Stress & Emotion 18394 While pilots should self-evaluate for stress and emotion during preflight mitigation analysis, stress and emotion do sometimes affect a flight in progress. External pressures from outside sources including supervisors, family, and friends may bias a pilot to make an error in an effort to complete a flight as originally planned. What does the pilot actually think about before making a decision? Does the desire to complete a flight as planned influence or outweigh the need to reduce risk? Only the pilot knows the thought process that leads to a decision, but making safety other than the top priority may cause the pilot to err. 18395 An emotional response could appear spontaneously and lead to an error at any time. After an emotional shock or an important life event, the pilot may not be able to concentrate on the current conditions. On the other hand, individuals may become relaxed during flight and may not be sufficiently alert to react to a threat or error. Occasionally, pilots overfly their destination because they have become completely relaxed. If here today, Aristotle would say that errors become more likely if the pilot is obsessed to the point of exclusion of all else or if the pilot is generally disinterested in the events at hand. Appropriate focus and concentration are the golden mean. Expectation Bias 18396 A pilot's erroneous assessment may persist even though it is wrong and despite available evidence to indicate the error. The term for this phenomenon is expectation bias. The NTSB has investigated numerous accidents and incidents that involved pilot errors resulting from expectation bias, particularly in night VMC when fewer cues aid in airport and runway identification. For example, in January 2014, a Boeing 737 landed at the wrong airport in Branson, Missouri, in night VMC. The flight crew expected that the visually identified airport and runway were the intended destination and did not reference flight deck displays to verify the airport and runway. As a result, the airplane landed on Runway 12 at M. Graham Clark Downtown Airport instead of Runway 14 at Branson Airport. 18397 A general aviation pilot routinely flew to a specific airport with parallel runways. The airport had one runway closed by NOTAM for several months, but after some time, the runway closure was reversed. The NOTAM was no longer for 19R/1L, but for 19L/1R. Even after reading the NOTAM and listening to the ATIS broadcast, the pilot perceived it as it had been previously. An error occurred when the pilot initiated an approach to the closed runway. 18398 When presented with conflicting information, some pilots will try to suppress that information if it does not fit in with the expectation rather than triggering an internal “uh-oh.” The phenomenon, not to be confused with expectation bias, has the slightly different name “confirmation bias.” The result of either, if uncorrected, may lead to an error. Either case results in the