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The Risks of Flying
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...Risk Analysis; ...Trying to Define Risk; Creating Risk; Reducing the Risks; How Safe Is Safe? ...On Reaching Overload; ...Situational Awareness; Immediate Action Items; Flying Is Not Traumatic, If; ...Complacency; ...Judgment; ...Cockpit Resource Management; An Application of CRM; ...CRM Training Uses DECIDE; ...Accident Factors are 80% the Pilot; Decision Making After the Accident; ...Advice from WWII; Precautions; When to Get Fuel; Defensive Flying Event Management; ..Wildlife on the Runway; Survival Revisited; Pilot Failure Causes Engine Failures; The When, How and What to Do; ...Emergencies Revisited; Training Your Instincts; Low Level Options; Autopilot; Fire; Simulation Problems; ...Simulated Engine Failures; Knowing the Risks; ...Airplanes Can Be Safer; ...Black Box Update; ...Opinion on electronic Failures; ...
More exact measurement techniques have given new precision to the process of determining the numbers to probabilities of a specific outcome of a series of events or of one event. This means that the FAA can decide with some accuracy as to how to allocate resources of personnel and technology to education, prevention, enforcement or punishment.
A pilot makes hundreds of risk assessments prior to, during and even after every phase of a given flight. Much of the risk management skills we use in our personal lives flows over to our flying. If we have failed to manage our perceptions of risk and reality in our personal lives, we are likely to have difficulty in our flying. Hence the FAA's interest our driving records and life style.
Airplane accidents are sources of spectacular deaths that attract media attention and political responses. The FAA as a political empire is very sensitive to the publicity of flight accidents because of the media impact. This is reason there is a historic correlation between an accident and the bringing into existence of an FAR.
The public has an enlarged presumption that every aircraft accident will lead to dramatic deaths and mysterious causes. The historical facts are that over 80% of aircraft accidents can be attributed to the pilot's inability to correctly assess the risk/probability factors being dealt with. It's called pilot error. Flying is a self-created risk program that is blown all out of proportion to the probability of a fatal occurrence. Only 6% of aircraft accidents result in serious injury or a fatality. The natural risks of everyday life are incorrectly perceived as less dangerous than the risks endemic to flying.
The FARs relating to flight safety are politically motivated by knee-jerk and special interest legislation. The FAA is forced into the committing of statistical homicide by applying limited resources to eliminate negligible risks. Flying will never be safe. Reduction of inherent risk in one area will only increase them in another.
The confidence of the poor pilot usually exceeds his ability to perform. Poor pilots are more prone to express this confidence than are competent pilots. There is a handholding relationship between the competent pilot and the recognition of this competence. The poor pilot's hand holding relationship is such that there is no recognition between skill required and the reality of what is required.
Conscientious pilots are noted for spending a proportionate greater amount of time in consideration of the flying they have done and are going to do. The pretentious among us would claim more for themselves and their aircraft than exists. There is something every pilot can do to remedy any proliferation of this condition.
1. Don't try to dominate pilot conversations.
2. Hand fly at every opportunity.
3. Fly new places and different aircraft.
4. Fly with anyone who will fly
5. Safe is not the same as risk free.
Trying to Define Risk:
To the degree that behavior is consistent and predictable it can be measured. Why do certain pilots take unnecessary risks? Student pilots are unlikely to take risks because they have entered a world of uncertainty and doubts. Private pilots at 5 to 500 hours are beginning to think that they know how to fly. The VFR pilot uses surface features to correlate position to the chart. Situational awareness is a region of comfort brought by knowing where you have been, are now and will be. Industrial accident studies have shown that a given risk situation can occur up to 300 times before an accident actually occurs. This type of study does not apply to flying or aircraft. In air and ground operations there are differences in that there is a consistent combination of elements that lead to accidents. Time is such an element. Weather is another element. Every flight, regardless of locality distance or time of day, contains the same elements of risk. Risk control improves as the pilot acquires preparation, proficiency, and situational awareness .
Flying a given direct route is about ten times more dangerous than driving the same route by road. Every person knows more people who have been killed while flying than they know who have been killed in cars. Flying is not as safe as pilots think it is. For every one-hundred million automobile miles fewer that two people are killed. Not quite two people are killed in every aircraft accident. One of these accidents occur every day of the year on average. Flying fatality rate is nearly 18 per one-hundred million miles. It would seem that the biggest factor of difference between the rates lies in the control the 'driver' has over what happens. Risk exposure in terms of what you can do about what happens is much greater in cars.
Pilots deliberately undertake a known risk every time they fly. Assumption that any existing risk is manageable can be instantly removed. Do pilots get better in assessment of risk? There is no certainty in life or flying. A pilot who is self-confident of his ability to fly complex aircraft into complex situations will not seek out these situations but will get gratification by showing that his mastery will actually reduce the risk. Such a pilot is cautious when dealing with the fuzzy areas of safety.
Safety is a fundamental in flight instruction. However, there are variations in the quality of the safety instruction being given. A student may be paranoid in his need to maintain a traffic watch. One of my recent students had, early on attended an AOPA seminar about mid-airs and arrived in my hands in such a condition. Mid-airs do occur but concomitant to this should be probability, survival rates and avoidance. The quality of safety instruction exists only in the totality of the presentation.
Recently, I was working a pilot through his flight review. Today took our second flight. Initially did some airwork after finding that pilot was unclear as to meaning of "Demonstrated Crosswind Capability". He indicated that he never flew in crosswinds above 13 knots. We got that straightened and also the use of flaps. Just as I did many years ago he believed that every landing had to use full flaps.
The higher aircraft performance the more efficient must be both traffic scan and radio procedures. Rate of closure often requires rapid interpretation and response as when a Hawker Jet was pointed-out to us. He failed to interpret the Hawker's five-mile final to our turning down wind. He looked all over the sky until I told him where and how to look Laziness is the source of inventive genius.
The poor landing is the place when a pilot can suffer the greatest damage to ego. Weather is where he is more likely to end the aging process. Weather accidents are more often to have serious or fatal results. The VFR pilot who challenges weather is raising the risk level of the entire flight. The IFR pilot on the same flight has an increased risk level but much lower than the VFR pilot because of a higher skill and experience level in dealing with weather. Both IFR and VFR pilots have greatly increased risk levels when flying at night. In all cases the primary risk of a pilot lies in the thought-processes available and used.
Beyond that, he never gave his altitude on any radio call. He had always believed that he was always giving position information to someone on the ground. When an airplane was pointed-out by ATC he never included his altitude as part of his location and response. He would continue to seek out and find an airplane even though its flight direction and altitude could not possibly pose a conflict. Being able to interpret the third dimension of traffic avoidance had never been taught to this particular pilot. Situational awareness must be three-dimensional. A decrease in ceiling and visibility is a major risk factor to the VFR pilot. The same ceiling and visibility need not be hazardous to the IFR pilot unless it is accompanied by turbulence. The risk is always there. A higher training level is one of the ways a pilot can control some areas of risk. Improved judgment usually accompanies additional training, or at least it should. A pilot must accept the fact that there is always some risk available and just waiting for the opportunity to become active.
Reducing the Risks
Pilots can reduce the already low probability of a midair collision by flying where risks are lowest. Avoid altitudes of even thousands and five hundreds. Fly standard patterns. Avoid VORs. Avoid airways and be vigilant when crossing since airways are eight miles wide. Do your airwork over hills when possible since direction requirements are effective when 3000 feet AGL. Know local obstacles as they intrude into your safe zones. Find your safe night altitudes during daylight. Don't fly IFR corridors during low visibility VFR.
Once you have determined where to fly safely, you are ready to use your eyes and communications. When making an arrival call-up use a prominent local checkpoint referencing your position one-mile to either side. Some checkpoints collect airplanes like flies. Try to use uncommon but known checkpoints both to educate ATC and other pilots. Always include your altitude in radio calls even to ATC. You do this as an advisory to other pilots. When making a departure I suggest that you request of ATC to proceed on-course to a specific destination. Wide angle departures such as downwind, crosswind, or straight-out can be valid over 90 degrees or more. A destination allows other pilots to draw a mental line as to where to look for you. Make a study of aircraft appearance and performance so you know what to look for and what to expect.
I teach a careful selection of flight areas, routes and altitudes for safety. It is not unusual for us to fly a two hour lesson without encountering a single aircraft in one of the most heavily flown areas of the world. When we do see aircraft it is remarkable how my emphasis upon unusual altitudes gives us an additional margin of safety. My expectation is that my students will pass this practice on to those pilots who come under their influence.
Just by staying out of high performance planes and adverse weather survival rates improve markedly. The aircraft that cuts travel time by a factor of three increases the accident probability factor by ten. What we do in the air is dangerous. Knowing the degree of risk exposure is vital information not often available to the inexperienced pilot. An accident is the end result of a chain of events. A short flight is statistically no safer than a long one. They both have an equal number of events that can and may go wrong.
Single pilot operations have an increase in risk factors. The single pilot is more likely to be ego driven to do things that would not be done before another pilot. Far too many pilots fly in a manner of seeking the reward of the thrill without being prepared to manage the risk. An airplane is a precious commodity that does not lend itself to carelessness or abuse.
Factors that both increase and decrease risk.
1. Self confidence
2. Organized and disciplined
3. Patient to avoid precipitous actions, yet willing to act.
4. Gathers information and updates when able.
5. Emotions are separated from decisions
6. Communicates easily
7. Committed to proficiency and currency
8. Gives precedence to safety over all other considerations.
9. Density altitude that is most likely to be ignored by operators of high performance aircraft.
10. When your brakes fail, consider changing seats to use the other set of brakes.
11. The computability of safety and conditioned behavior is open to question.
12. Find an appropriate and expedient way to resolve problems.
How Safe is Safe?
--There is no absence of risk in flying.
--Every accident comes through a sequence of compromises.
--Complacency is the most avoidable compromise.
--Acceptance of deficiency is most dangerous compromise
--Personal considerations cause the next compromise.
--Unfamiliarity breeds the next.
--Conflict avoidance comes as the next compromise
--Weigh compromises against what occurs next.
--Worst compromise is when 'needs' exceed safety considerations.
On Reaching Overload
A pilot is occasionally faced with a situation that pushes his envelope of competence. Usually this situation arises through an accumulation of pilot performance or non-performance. Occasionally aircraft systems design or the ATC requirements push the envelope. It is important that the pilot recognize the potential performance stress when it arises, and more importantly to see the rise of negative decision making factors.
Decision making of the dangerous kind has many warning signs brought on by stress on your performance envelope. You will become uncertain of what your options are. You will have difficulty making a choice of an option. You will fixate, focus, and become preoccupied with your one choice. Time will become distorted so that the sequence of events will
Poor judgment is quite likely to be a matter of 'situational inertia' which is a distraction than interrupts the decision making process. The pilot becomes redirected and focused on an unrelated situation that is not related to the actual problem. This subsidiary matter inhibits the pilot's ability to interpret information in its proper context. The resulting decision is wrong and contrary to good operating procedures or the FARs. Situational inertia moves the pilot inexorably into a accident. The NTSB calls it a matter of poor judgment.
The normal thinking reaction to an emergency is a concentration of thought is on your perception of what occurred. The rise of tension along with focus on attention blocks out everything else thus limiting your ability to make use of other peripheral and available resources. this means that while you may be dealing with the emergency at the same time you are not dealing with the ordinary functions involving just flying the aircraft.
When a traumatic situation occurs there is a twisting and brevity of the time sequence as things take place. Things happen in much less time. This compression prevents us from doing the ordinary things listed on your checklists. This is a situational warning that means dealing with the emergency should not (emphasis NOT) interfere with doing what is ordinary as part of flying the aircraft.
Your best recourse is to have a PLAN. Decide not to spend time on the high-tech aids. Fly the plane. Manage the basic resources that keep the plane in the air and on course. Use other pilot cockpit resources or ATC to release the pressure and divert distractions Use the preflight as a time to leave the pre-flighter alone. Interruptions during preflight are rude, dangerous, and inappropriate.
Situational awareness refers to what is going on around you and the aircraft. This is more than just your location. It means being aware of other aircraft, the weather, fuel, and all the other factors that contribute to safety. Flying is encompassed by dynamic changes. Unless we are prepared to deal with and react to those changes we are going to get 'behind' the aircraft and the situation. Situational awareness requires recognition of where you are and knowledge of the sequence of events that commonly precede creation of a problem. Preparation for a specific flight is the most advantageous thing a pilot can do to avoid unexpected situational problems. By knowing an area and the airport a pilot can pre-plan the arrival and the communications. Even so, the unexpected can and will occur.
There are several actions you can take to control the unexpected. Know the area and the airport. Know your aircraft its performance and limitations. Know your own abilities and limitations. Slow down the aircraft. Keep track of your aircraft configuration as to power, flaps, trim and speed. Know how to go from any configuration to another. Fly heading and altitude. Navigate. Fly assigned headings and required turns. Have a standardized use of the checklist and procedure. When the aircraft and navigation are under control, communicate. State your concept of the problem and follow directions.
Work assertively (see material on assertiveness) to maintain situational awareness. Locate and note safe clearance altitudes of terrain in the daytime as a factor you will need at night. Learn local instrument procedure terms and locations as a VFR pilot. You will be able to avoid these locations when flying MVFR (marginal VFR). Never rely solely on ATC (Air Traffic Control) to keep you clear of obstacles or especially aircraft.
If you have not prepared for a flight out of your knowledge area you will likely suffer from 'geographic disorientation'. It happens to everyone and the best of pilots. It is most likely to occur in the summer due to a pilot's belief in what he is seeing compared to what he has expected to see. Operational causes such as planning, communication, and in-flight distractions come next. Lastly, the flight environment may preclude seeing what needs to be seen, hearing what should be heard, and knowing what should be known.
Perhaps the most neglected situation as far as awareness is concerned is the condition of the pilot. Don't go flying if you have a personal problem. Family, health, business and personal problem will affect your airworthiness. Flying can be a great emotional escape but not while you are learning.
Immediate Action Items
1. Fly the plane
2. Go to slow cruise
3. Trim for hands-off
4. Assess the options
5. Check fuel for time remaining
6. Contact ATC or 121.5
7. Select your considered option
D. Detect what is wrong
E. Estimate the significance of the problem
C. Choose the safest outcome
I. Identify most reasonable actions
Do take positive action
Evaluate the action taken by finding airport or best off airport for power available.
Causes of diminished Situational Awareness
1. Pilot is preoccupied, distracted and or fatigued
2. Pilot has a growing concern that something is not as it should be
3. In some principle parameter the flight is proceeding as planned
4. One or more instrument readings is a cause for concern
5. The pilot is spending more and more time in the cockpit instead of outside
Flying Is Not Traumatic If...
1. You prepare adequately and make use of resources.
2. You make flying a non stressful event.
3. You keep a supply of options available.
4. You know where you are.
5. You do not try to stretch a glide out of ground effect.
6. You hit the ground in level flight.
7. You avoid stalling into the ground.
8. You use all the structure to take the shock, except the nose.
9. You don't go for the ride. Keep doing something.
10. You keep speed and control as long as possible.
The other side of the anxiety coin is complacency. This is often the 'it-can't-happen-to-me' syndrome. Complacency can be caused by a sense of security, fixation caused by concentration on one aspect of the environment, an overload of assumed responsibility for one aspect to the neglect of others or most likely ignorance. It's pseudo-agnosia again. We don't know what we don't know. We are letting "George" (autopilot) or Air Traffic Control (ATC) look out for our well being. It is more difficult to back through events that do not result in accidents.
Complacency falls apart and difficulties compound when those crutches we have relied on are either not there or fail to produce desired effects. Runway configurations change at different airports, patterns differ from our expectations, and controls fail to perform as instinct tell us they should. A pilot spends many hours unlearning instinctive reactions that won't work. A proficient pilot practices those skills that prove instinctive reactions won't work.
Spent a few days thinking over the teaching of judgment and then consulted with my bitter-half. Her contention is that you either have common sense our you don't. I always wondered why I always bet on the "don't" when playing craps. Nevertheless, I do have some strong opinions on the teaching of flying judgment. Other opinions to the contrary, I feel that a student pilot cannot learn the desired judgment with out exposure to the actual situation.
Many aspects of flying require exposure to the mistakes of flying. It is just as important to be exposed to the mistakes of landings as it is to the correct procedures. Stalls are taught as flying mistakes to be avoided. The correct performance is taught as a recognition skill rather than as a performance skill. So do I teach VFR weather flying. A student pilot who has only been told about SVFR and flying in minimum conditions will never appreciate the complexity of knowledge and decisions that need to be made.
Just how much weather I give a student depends upon how he seems to expect to utilize flying. The student who expect to use flying as an efficiency tool in his work needs a different approach than the student who expects to be mainly recreational. I never cease to be amazed by the number of pilots that I give flight reviews to, who have never done a SVFR flight or flown MVFR. More than a few have been unexpectedly trapped in these conditions with which they had no prior training. A student needs to know where the IFR approach routes and altitudes are. Then he must know to stay away from that area in times of marginal visibility.
I have always advocated a student learn to fly in the Fall and Winter so that you get your rating being exposed to adverse conditions and learn to make fly/no fly decisions under guidance. The S.F. Bay Area where I fly has many adjacent valleys where meso-scale weather varies greatly. A pilot needs to learn to read Bay Area weather if an airplane is going to be an effective working tool. A student who learns in the Spring and Summer is totally unprepared for Fall and Winter weather. He simply stops flying, only to find that the hiatus now requires the additional cost of dual to regain proficiency. A very high proportion of new pilots never fly again. Often those, who challenge the weather without training, appear in the evening news.
In teaching to fly the weather I have several specific parameters. First, I always fly toward improving weather. That implies that I fly away from deteriorating weather. Second, I always leave myself an out and usually more than one. I know where I am. I have more than adequate fuel reserves. Last, I am never reluctant to get help. The overly proud pilot who feels that his training has taught him all that needs knowing, who is unwilling to admit being misplaced or lost, is just flying toward future trouble.
I was able to deliver four planeloads of clothing to Watsonville flying VFR after the '87 earthquake while IFR flights were lucky to make one. The weather was MVFR but good enough for an area-familiar pilot. On TV the next day I saw the clothes we brought, getting wet from the rain. No one thought to fly in tarps.
I teach weather flying by adjusting to the conditions as they exist. I do not fly in 600' ceilings, 2 mile visibility, turbulence, or SVFR for fun. I will and do fly with students in these conditions to teach them how to deal with the situation. I teach that the VOR is very limited at low altitudes. The ADF less so. The GPS is now the future. There is little reason for a pilot to become lost now. Radar coverage is being extended every year to more and more airports. The AWOS weather program will soon be widely available. Things are getting better. However, these advances will cause more and more pilots to push their experience envelope. Many will be relying on technology when the only aid available will be the Mark-I eyeball. I teach the eyeball system. The eye is always looking for options.
Made a dual night flight with a student where there was a dew point -temperature spread that was relatively close. This meant that fog could form if it became closer. As we went in and out of other nearby airports we made an ATIS check of our home field just to make sure that we would be able to get back in. Was this teaching judgment? I would think so. The ultimate weather option is to land and arrange other transportation. I have done this more than once because of ice, winds, turbulence, and aircraft performance.
The relative safety of a situation depends upon pilot experience and evaluation of the alternatives. Doing a dumb thing successfully skews your judgment. You think you can get away with it again. What ever induced a pilot to perform in such a manner? Success? The 'risk management' process is often so flawed by presumptions of success that failure is inevitable. The pilot is the leading cause of all preventable accidents. Prevention is a blend of capability, preparation and attitude. Learning your limits in flight training is what it's all about.
All activities involve some degree of risk. Flying, due to its multi-dimensional complexity, has more than its share. Risk can be managed if the pilot has properly prepared for the flight and is proficient and current in the required skills. Preparation is mental, physical and mechanical. Proficiency requires recent flying in aircraft type and weather conditions. 72% of pilot accidents have occurred where pilots are not trained or current in the conditions surrounding the accident. You can be trained for flying in minimum conditions. Such training deliberately selected is more productive in developing judgment than those, which occur as surprises develop.
Since poor judgment is involved in so may accidents we should know that an unfamiliar situation is a breeding ground for poor decisions. An airplane can be flown into an abnormal situation faster than your decisions can get you out. The critical decision is one of determining what is most important? Risks are often best minimized by landing. Good judgment can be taught and learned. When in doubt, make the safe decision.
The Source of Good Decisions
--In place procedures
--Experience gives perspective
--We accept Murphy as a possibility
--Experience gives us a collection of options
--Experience is a great teacher if you survive
--Fly the airplane first
--Approach each situation with distrust
--Challenge every decision
--All decisions are temporary
--All decisions are conditional
--Ask questions and make quick decisions
The wise man learns from his experiences; the wiser man learns from the experiences of others. Many receive advice, only the wise profit from it.
Cockpit Resource Management
CRM is the integration of pilot, aircraft and environment for safe efficient flight. CRM is required by the FAA Practical Test Standards. The pilot is expected to have prepared and organized his materials and procedures with safety and efficiency in mind. The setting of priorities, monitoring procedures, and problem solving will be part of your flight instruction. Given a choice between amount of knowledge and amount of skill related to flying, take knowledge. Knowledge will allow even the most unskillful pilot to avoid situations beyond his skill. Reliance on assumed skill has killed many a pilot who lacked the decision-making knowledge that would have reduced the need for skill in the first place.
The better you know and utilize the outer performance ranges of a given aircraft in your everyday familiar situations the better prepared you will be when these performances are actually required. On a given hard surface you should know the actual ground roll for several selected gross weights not just what the manual says they should be. How much altitude will you lose in a 240-degree power off turn at 30 and 45 degrees of bank. Plus a margin, this knowledge may make possible a return to a departure runway or at least give a yardstick by which a pilot can measure his ability in a particular aircraft.
It is not just enough to have resources in the cockpit. Charts, tools, flashlights and computers must be reachable. One form of useful time in an airplane is knowing where and how to get what is needed. Plan on the ground for what may happen in the air. Little things make a big difference. Do you retrace steps while preflighting? Did you "clear" before lowering flaps? Did you carry all needed materials but especially the checklist? If you start now, at what time should you be on ground for refueling?
Do you get your ducks in a row before starting the engine? How about passengers seat belt? Have you decided on what you are going to say to ground and tower. Which way are you going. Do you have a prepared frequencies list specific to this flight? Is your map open and folded to encompass the flight area? You will hold the map up for study instead of looking down. Is your checklist such that it can be used without looking down into the cockpit. Once under way. Do you divide attention in and out of the cockpit proportionate to the requirements of safety. Do you both communicate efficiently and listen effectively. How do you deal with difficulties of situational awareness? Are you prepared to admit difficulties in hearing, locating, or aircraft performance.
An Application of CRM
There is no backup for the altimeter. An inoperative altimeter along with the VSI indicates a static system problem. The problem can be solved by use of the alternate air. Another failure is the Kollsman Window setting knob. This failure tends to be progressive and should be fixed before total failure occurs.
A total failure of the altimeter can be partially overcome by getting your altitude information from a radar facility getting readings from the blind encoder of your Mode C transponder. You would be able to shoot a PAR approach without an altimeter. Find out where your nearest PAR approach exists. Check for a Naval Air Station.
Pilot may reaction emotionally or instinctively
Pilot may have locked in mind-set as to what to do.
Pilot may have overwhelming get-there-itis.
(Phone 703 487-4650 for training books)
1. Awareness by sharing sense of a problem.
2. Risk analysis by sharing sense of options available.
3. Decision time with statement of solution
Newest addition to CRM is Error Management
CRM is a team effort used to resolve problems. Where everything in the cockpit is done the same way, talked about as it is being done, and verified by another crew member, mistakes are less likely to happen. Tasks are completed from memory in a flow and then checked by a challenge/response verification.
Even a single pilot can use verbal confirmation of his cockpit activities. Hearing is a key element in the verification of what is done by the pilot. Every student pilot should learn to talk to himself as a means of verification. Anything said aloud is more apt to be detected as an error that just thinking through a checklist by memory. Learn to talk through your procedures and maneuvers.
Be doing, talking, and verifying a single pilot or a crew can 'trap' errors before they multiply into accidents. When in a two-pilot or crew situation, the right seater will always verbalize any action that he takes to the pilot flying. Pushing, pulling, sliding, twisting, whatever. Say it aloud.
Mistakes will occur regardless and when they are not 'trapped' accidents will occur. When an error is committed and not trapped then the full force of CRM must be employed to mitigate the problem. Every source must be milked for ideas, suggestions, and assistance.
CRM training uses DECIDE
-- (D)--Detect that a change as occurred.
-- (E)--Estimate the significance of the change.
--(C)--Choose a safe outcome.
--(I)--Identify plausible actions to control the change.
--(E)--Evaluate the effect of the action.
The essentials of CRM in a situational awareness problem would follow several scenarios. You are lost, misplaced, confused, or disoriented.
(D)--You recognize that you are experiencing a problem.
(E) You estimate the problem ...........................................(E) You are unable to estimate
as not serious. the seriousness of the problem.
(C) You continue as before (..............................................C) You make a decision to:
make a change.
(I) Your sought for point is ................................................(I) You choose to turn, descend, climb,
just ahead. or communicate.
(D) By not doing anything you ...........................................(D) Your action does not provide
do something a solution
(E) The sought for point appears........................................ (E) You evaluate failure and start
where it is supposed to be. .......................................................the process over again.
Cockpit Resource Management can be taught. It involves a pilot's understanding of his own life patterns, motivations, stresses, health, and ego concept. The better you understand yourself the safer you can make your flying. As a child I was subjected to much frustration due to adult abuse of time constraints. This has resulted in my feeling stress when time is involved. As a result I make every effort to allow enough flexibility in my plans and schedule so as to avoid my own personal stress problem.
Accident factors are 80% the pilot
--Pilot's improper calculations which resulted in fuel exhaustion.
--Failure to use checklist.
--Pilots continued operation of the airplane with a known deficiency.
Decision Making After the Accident
1. Desire to 'get it over' creates tunnel-vision.
2. Hope is to 'get-away-with-it perhaps by leaving the scene.
3. Give student a picture and poise a 'what-if' question as homework
4. "Think outside the box" to learn all available choices.
5. Teach hood 180 procedure to an immediate local landing as weather avoidance procedure.
6. Refere to AC 60-20
7. Always keep an out.
8. 52% of fatal accidents are caused by poor aeronautical decision making.
Advice from WWII
During WWII new pilots were give a booklet of "Lessons that Live"
In brief form they are:
1. To live long, plan well. Take advantage of every scrap of information available that may affect your flight or flying. Chance may get you by; careful planning WILL get you by.
2. Fly high. On routine flights of all kinds, unless there is some very good reason for doing otherwise, get up and stay up. The more sky you have below you, the more time you have to think and act if something happens.
3. Nine out of ten accidents are the direct result of disobeying flying regulations and the rules of common sense. Experience may be the best teacher, but along with experience, if you get it the hard way, can come bitter sorrow and searing memories.
4. No instrument has yet been invented to keep the human brain from cutting out occasionally. When you're in that cockpit, forget everything else and devote all your attention to flying your airplane.
5. Beware that period in your flying career when you begin thinking you are good enough to abandon the habits drilled into you by your flight instructor. All the piloting ability in the world won't make up for sloppy preparation before takeoff.
6. Except under very unusual circumstances, there is almost no conceivable emergency that justifies a departure from the well-defined flying rules and regulations. Never allow your emotions to overcome your better judgment.
7. Flying an airplane is a full-time job requiring the pilot's individual attention. A little horseplay now and then may be all right on the ground, but when you are flying you should forget all that foolishness.
8. Make everything right on the ground and you will have a minimum of trouble in the air. Always start with everything in your favor. It is deliberately inviting disaster to takeoff with any doubt in your mind."
9. Fly that last mile as well as the first. "Happy Landings" means just what it says. Ordinarily there is no reason to take any chances when landing. At the home airdrome, good judgment and technique are just as important at the last minute of the flight as at the first.
10. The majority of all airplane accidents are causes by one of two things: faulty supervision or pilot error. No substantial drop in the number of accidents can be expected until pilots and flight instructors take it upon themselves the personal responsibility of preventing them.
11. Ignorance is sometimes blamed for pilot troubles. Ignorance is never an excuse because the training program required by the FAA is thorough. A pilot's ignorance is a poor excuse for errors in judgment, plain boners, and faulty planning, and the lack of alertness.
12. A good pilot knows his own limitations and the limitations of the particular plane he is flying. If a pilot is lacking in experience, he is a fool not to accept the advice of those who know.
13. Carelessness in checking your aircraft and its logbooks is a cardinal
sin of flying. Many an accident would never have happened if the pilot had
taken the simple precaution of checking the condition of the airplane before
1. When radar points out traffic. Acknowledge...wait 30 seconds and advise them that you will accept a traffic avoidance vector if you have not found the traffic. Always include your altitude and position when you communicate.
2. Watch out for 'position reports'. Many pilots habitually call their position by what they see ahead rather than what they are over.
3. When a non-radar ATC gives you a traffic advisory, or you hear an aircraft give a position get on the radio. Give not only your position but also your altitude. You can miss aircraft by altitude as well as by position especially if you are at an unfamiliar airport. Ask ATC to query the other aircraft for his altitude.
4. I try to avoid reporting directly over common reporting points. It is far safer to report one-East or such from the point. The offset may save your life.
5. Any time you are flying within 3000 feet of the ground, you will be better off flying at altitudes that do not end in three zeros, five and two zeros or any number ending with 00. What I have in mind is altitudes similar to 2750, 2350 and 1850 AGL etc.
When to Get Fuel
With the advent of LORAN and GPS more and more pilots are being fed accurate info as to when and far away they will arrive at any given point. As they become gradually aware of an inaccurate fuel gauge and a fuel remaining time deficit there arises a conflict. The closer the destination or planned stop the more difficult will be the pilot's decision. I my planning I pre-decide that I will not press on, I will land, refuel and pick a new 'next' refuel stop.
One device for never running out of fuel in an aircraft that gravity feeds from both tanks is to switch to the last tank reading a quarter full. Run that tank dry and then land using the other tank. This procedure should be practiced to confirm how much fuel remaining exists at the quarter full indication.
By keeping accurate track of your ground speed and time flown on your route chart you can make your refuel decision earlier. The more complex your aircraft the sooner you must review the restart procedure so the brain won't fold up on you.
The vast majority of pilots, I am familiar with, tend to be aggressive in their flying; offensive that is. This requires that the remainder of non-offensive pilots be defensive for survival's sake. As in football, defense wins more games than offense. Defensive flying begins before you get to the airport. You have checked the weather, NOTAMS and your personal flying kit. On arrival, after surviving the traffic travail, you have checked the runway in use; surface winds, and confirmed the airworthiness of your airplane and its ability to make the planned flight. Statistics indicate that at least 25% of flight problems are due to inadequate flight preparation. It's all called preflight.
The pilot who limits his knowledge to the things that he is supposed to know is headed for trouble. For everything you are supposed to know there are at least ten related nice to know things related to what is happening and going to happen to you and your airplane. It is not just enough to tend to your responsibilities; you must be prepared to protect your interests by being aware of how others are doing their job. Your best self-defense is directly related to your total awareness of what others are doing close to your airspace. Said another way. You, of necessity, must rely on the performance of others. Likewise, you of necessity must protect yourself from the malfeasance, misfeasance and nonfeasance of others. Just like driving in traffic.
Our accident driven FAA and its FAR whip can be supplemented by quite a collection of planned flying activities. Annoy ATC a bit by avoiding the middle of airways. Don't taxi into position on the centerline. Offset a bit so you can see what coming. Don't taxi on to the runway without clearing the base legs. Both of them. Fly altitudes, weather and places where others are unlikely to fly. When weather's bad consider reserving the top thousand feet of a Class Delta airspace footprint for doing airwork. Another choice I make is under the shelves of Class Bravo. You can get radar advisories while flying in airspace others avoid. Proper use of the radio can get you many ATC preferences just by asking for 270 departures, direct entry into downwind, modified base, crosswind runway, and more. Even when crossing 7000-foot mountains I like to fly within 3000 feet of the terrain where any altitude is legal. Statistically, you are more endangered flying by the hemispheric rule than as a renegade.
Being a defensive pilot requires making an assumption. Assume, in every situation, the worst possible scenario is going to occur. The winds are never as forecast. Weather avoids being predictable. Fuel is always above planned consumption and fuel remaining is less that desired. There are more headwinds than tailwinds. Bad weather arrives sooner; good weather may not be there at all. The skeptical pilot is a survivor. The optimist expects too much and will get too little. The skeptic will only have himself to blame for what happens.
This is an emergency process where the first thing you do is 'ignore' the enunciator light. You disengage from doing anything and wait to see if there are any obvious symptoms of a problem. Then you prioritize what you are going to do.
Wildlife on the Runway
The FAA maintains a database on wildlife strike occurrences. Since 1983, there have been 245 deer-related accidents that have caused serious damage to aircraft, averaging about $96,000 in damage per incident for the ones who provided estimates. Wildlife strikes should be reported to the FAA on Form 5200-7, which can be found in the "Aeronautical Information Manual" as Appendix 1. For more
The nature of uncertainty is what makes piloting a field of considered risk taking. There is no certainty in any pilot decision only a degree of probability. The trained pilot is, or should be, well informed in recognition of the wide
collection of hazards existing in aviation. A partial list of these would be weather, airspace, electronic, mechanical, instrumental, geographic, topographic, intestinal, attitudinal, social, physiological, medical, personal and governmental. On any flight every one of these problem area poise a decision making oppportunity. One element that exists in common to all of these is time. I will touch briefly on some of these here and the rest at a later time.
The element of time as a safety factor is the essential element to flight planning. While every accident is an accumulation of events of variable time intervals, the accident itself takes but a moment. Preparation for an
accident is usually for survival afterwards, while the need is for prevention or evasion. The actual event offers little time for either prevention or evasion. In moments, the placid smoothness of controlled flight becomes erratic, hectic and uncontrollable. Power either runs amuck or ceases completely, configuration becomes the speed control most likely to be effective. All flight efforts should be to maintain the sufficient control required for normal landing attitude while moving as slow as possible. At the present time there is no way to accurately
determine just what the pilot did in the cockpit to cause an accident.
In general altitude is your friend if you have control. On takeoff use Vy for as long as practical. Fly airport vicinity routes and high tight landing patterns. Learn how and where to look for traffic and fly at altitudes somewhat off the even thousands and five hundreds. On the other hand the closer to the ground you are the slower you can maintain controlled flight the better. Aircraft structure is designed to crumple and absorb shock use it to your advantage while keeping yourself from bouncing off interior surfaces.
I would suggest that we not be over concerned about midair collisions. The laws of probability seem to indicate that looking and not looking will have little effect on the number of annual occurrence. Also, half of the people involved in midair collisions survive. There are far more effective use of time and money in aviation safety that mid-airs and runway incursions. I have always made a point of clearing the final and base approaches to a runway before taking the runway for takeoff. Yet, hardly a takeoff by me is not preceded by an aircraft departing without such a clearing procedure. I have avoided an accident by this procedure only twice in an estimated 20,000 landings. There is more than luck in becoming an old pilot.
It is all too easy to expect government regulation to take the element of chance out of flying. There is overwhelming evidence that governmental lethargy is directly responsible for thousands of aviation deaths. The vast majority of these were operationally weather related to WWII and not due to combat. The ILS existed in 1930 with the same ability as it has today, yet it was never accepted by our aviation agencies as a basic safe landing procedure until well after 1950. A present example of this lethargy now exists in our ability to confirm the accuracy or inaccuracy of the VOR through the use of the GPS. Far less accurate methods are required by governmental rule.
The day is here where the use of electronic ignition, turbine power, composite construction, and satellite navigation will be factored into general aviation regardless of bureaucratic resistance. There is no reason to believe that anything the government has done regarding the standards of medical or aircraft certification have appreciably improved aviation safety. On the other hand there is every reason to believe that the fear of change, the fear of responsibility, and avoidance of initiative have inhibited progress and safety. In the meantime the pilot's best safety option is to play it safe by making the most conservative decision.
Causes Engine Failures
--Aircraft engines are not prone to failure regardless of make
--Major problems are lack of use and exterior weather
--Engines are most likely to lose power because of the pilot.
--Fuel problems can only be prevented by the pilot.
--Carburetor ice can only be removed or prevented by the pilot
--Those who have had engine failures are more aware that the event can happen again.
--Confirm fuel to engine before starting
--Be ready to abort if things don't sound, feel or seem right
--Get as high as you can as soon as you can
--Fly an airport vicinity route and change tanks when approaching airports
--Fly at altitudes that allow restart time
--Fly by time not by gauges
--Single engine night flight raises the odds against you as does terrain, visibility and fatigue
--Shallow approaches are inherently more dangerous than steep approaches, especially at night
--Make your own 'level of awareness' list to read occasionally
The When, How
and What to Do
--Trust your preparation and training by knowing what to do, doing it and checking afterwards.
--Doing the right thing on time and luck will make the difference between success and failure
--Training should consist of simulations at various altitudes, winds and locations
--Decisions are easiest at low altitudes because your options are limited.
--First, fly the plane
--Trim all the way nose up for maximum time in the air and adjust for penetration as needed.
--Exact Vref glide speed is 1.3 of the actual weight.
--Save all the altitude possible while looking for a place to land.
--Perfect is usually not available so pick least undesirable near source of help
--Do not let wind blow you short of intended field. Being high is more easily resolved than being low.
--Try to restore power buy moving every engine control, fuel control, air control, and spark control.
(I pulled Mixture way out at 800' on engine failure only to have engine start again. Stuck carburetor float.)
--One magneto may work when two will not, open alternate air,
--Communicate on known local frequency or 121.5 and say everything three times
--Don't quit trying.
--A larger landing space is always preferable to anything small.
--Keep close but not too close. Practice power-off approaches to learn things you need to know.
--Save flaps until last.
--FARs allow deviation from regulations as required to meet the emergency
--Only upon the request of an FAA agent are you required to send a written report
--There is no time requirement either for the FAA or the pilot to request or submit the report.
--A pilot who is given ATC priority in an emergency shall on ATC request submit within 48 hours a full report.
--FAR 91.123(d) (above) has three requirements, an emergency, ATC priority and ATC request.
Training Your Instincts
--If you become concerned about a situation it is your instinct at work.
--Concern is a sign that you should get training.
--Training gives you methods to determine the degree of risk that exists.
--Training prepares you to do the right thing when the wrong thing happens.
--Training reduces the concern factor by increasing the options to be selected.
--A decision not to fly because of ice, fog, thunderstorms and high winds is always a good one.
--In flying, life-saving behaviors are better directed by trained reflex rather than by instinctive reflex.
--Training should be directed towards concept, procedure, or skills needed to deal with events.
--The known should be fuel quantity, time in tanks, weight limits, balance and performance limits.
--'Unknown' can only be trained for if properly communicated
--Good instruction includes anticipation of the 'unknowns' likely to exist for the student.
--Good instruction includes teaching/allowing the student to communicate his 'unknown' concerns.
--Proper training allows the student to develop the knowledge and skills to deal with concerns.
--Flying without concerns are only when pilot has accepted the existing risks and his ability to cope.
--Frequent flyers are less likely to have concerns
--Dedicated practice is the best use of flying time
--Once a month dedicate a flight to currency, new places, POH extremes and the seldom used.
--Any sense of trepidation about any safety aspect is reason to make a significant change.
Low Level Options
--Viable option if paid to fly low.
--Average of five deaths per month.
--Accident rate is 60 percent higher in Alaska
--Most often legal but not wise.
--Low altitude mixed with ignorance is a losing situation
--Is untested and used often
--Not on checklists
--Checklist does not include failure modes of autopilot
--Every make and model difference may have a different failure mode.
--Autopilot maintenance is not normally a part of the annual.
--The autopilot disconnect on failure does not always work.
--Some autopilots are unable to adapt to abrupt manual over-ride.
--Late models of autopilot will fail when the altitude encoder fails.
--Some autopilot 'bridles' get loose with age and are unable to keep up with aircraft oscillations.
--First level of operation should be all the options to disconnect autopilot
--Not usually a part of renters checkout
--Different brands and series have variegated failure modes
--Altitude hold feature can result in structural failure when some inflight failures occur
--Autopilot depends on other instruments to set performance.
--Auto pilot operation are either horizon (position) bases or rate based.
--Horizon based autopilots usually use the attitude indicator as a driver
--Gyro can tumble, vacuum can fail
--Disconnect autopilot in turbulence but only after gaining manual control of yoke and scan.
--Rate based autopilots work off the turn coordinator along with an accelerometer.
--All electric but alternator failure is backed up by battery to allow reaching VFR.
--Altitude hold of autopilot uses electric trim. Increased risk of if pilot uses yoke.
--Any autopilot failure at speeds over Va can cause aircraft to self-destruct.
--Autopilot failures should be practiced
--Reliance on autopilot will reduce manual proficiency.
--breaking of hoses, fittings, heat deterioration, chafed wires, piston holes, preignition (Sets oil on fire)
First Sign of Smoke
--Master off, selector off, mixture off --Fly the plane
--Turn off air vents--Fly the plane
--Sideslip--Fly the plane
--Get down as quickly as you can--Fly the plane
--Open cowl flaps, dive to blow out fire--Fly the plane
There is no assurance that our training will be effective in a future similar situation. Even slight changes in the situation can elicit reactions that are inappropriate. Anticipation is an essential to flying proficiency but when it is replaced by expectancy unforeseen problems arise. All too often we use training procedures that do not properly prepare a pilot for the real emergency or situation. A classic example is the touch and go transition which is a contrary procedure from that of a normal landing and takeoff.
We are not allowing students to experience the stress situations that are common to all flying. The turbulence, wind gusts, engine hiccups, radio difficulties, or cockpit problems... Talking and dry-runs are not sufficient. All of these require the pilot to think first and act later. The conditioned response is very likely to be the wrong response. A switch or lever is NOT released or considered completed until verified by instrument and visual check where possible.
--Recommended method is reduction of power to slightly above idle.
--Periodic power increases during descent is acceptable safety precaution.
--About eight engine failure simulations result in actual accidents every year.
--All the accidents were judged preventable with exercise of proper judgment of ability.
--Recommendation is that no simulations be made below 2000' and then treated as an actual
--Using the mixture is not recommended as means of causing engine failure for several reasons
--Turbo engines are subject to shock cooling so power failure simulations are not recommended.
--A magneto shutdown will leave fuel in the cylinders and a moved propeller could fire a cylinder.
--The practice of shutting down an engine with mixture rather than magnetos is to protect people not engines.
Knowing the Risks
--IFR accidents are nearly always fatal.
--An impact from the side will kill you if it exceeds 9G.
--An unintentional spin is a stall accident that has an 82% fatality rate.
--The human body can only survive a 15G vertical impact.
--Rear facing seats allow the human body to withstand an 83G impact.
--GA crashes: 49% of occupants have no injuries; 18% have minor injuries; 22% died.
--90% of fatal injuries are caused by impact of bodies striking aircraft structure,
--Fatalities result in the 30th percentile when occurring in urban areas and trees.
--1/4 of mountain accidents result in impact deaths. 4 in10 resulted in serious injuries.
--An accident that occurs in a field is 75% less likely to cause impact related deaths or injury.
--A single engine ditching accident has less than one in ten chance of fatality if impact is controlled.
--Survival is most assured when body impact is less than 45G straight ahead while aircraft is under control.
--A passenger has every right to expect a pilot to conduct the flight without compromising safety.
--Any use of the autopilot should be delayed until at a safe altitude.
--Unless required by special circumstances FAA records are destroyed after 30 days.
--An aircraft mechanic is required to sign off any maintenance performed.
--Nothing excuses the pilot in command from having an in depth knowledge of
the aircraft he is flying
--The PIC bears the sole responsibility for the safe conduct of any flight.
--Aviation's maintenance system is built upon trust that parts and workmanship are within regulations.
Airplanes Can Be Safer
--Fly slower under control
--More controlled landings
--Protected fuel tanks and lines out of cockpit
--Digital engine control
--9-G seats and restraints
--Improved crash worthiness
--Controlled emergency descents
I think everyone is well aware what the black box does on an aircraft. Mind you, we only hear about them if a plane crashes. It kind of provides a postmortem. A little Canadian company has the technology to replace the 'black box' and actually provide the data real time and in such a way that problems can be detected before they happen.
Opinion on Electronic Failures
It is good to know that most folks have a high confidence in the new gadgets. But I have been speaking from my own experience dealing with the communication systems (hardware and software) used in the major networks around the world. At least one metropolitan 911 systems ran over our solutions.
Vast majority of our customers think our stuff can never fail, but there
always a few ones in big big
trouble, and we can never eradicate these sources. There appears to be a misperception of software system reliability. It is different from hardware/mechanical systems, in that a mechanical/electronic
system's failure rate is much higher at the beginning of the life cycle, and reduces quickly thereafter, before it picks up quickly at the "end" of the component's life cycle.
Software, however, exhibits a different behavior. "Older" software appears more "reliable". But its
reliability completely relies on the test that can exercise all the possibly logical decisions given all the combinations of the input to the system. This is why a software logic of 1+1 =2 will never fail
once it is shown to work at the first time; however an un-exercised decision, e.g. due to an unusual
sequence or timing of input, is the most uncertain and dangerous. There are cases when a system can completely fail due to a seemingly benign diagnostic print statement accessing a wrong part of the memory address space.
The statement is never executed unless an unusual situation arises. Since it is only reached in unusual situations, it is hard to get to in the tests since humans are not well suited to predict the unknowns...
The more complex (more functions) the system, the more likely it can fail in the most catastrophic way. I took some reliability theory courses and none of them can be applied to software system algorithmically.
Back to the phone/computer communication systems, they are extremely tough systems to maintain, and they do fail (the old TDM switches were more reliable mostly due to the lack of functions, and disability in adding features). The network service providers have lengthy procedures to qualify the
software systems they deploy. Note that those are done at the customer side, beyond the vendor's
delivery. And they still fail.
Two important observations:
One, the airplane glass cockpits seldom go through the rigorous tests on the customer side after they are delivered (well they do, with the pilots lives on the line after deployment);
Two, the added convenience/reliance of the "extra awareness" gives a false sense of safety, it only feels that way when it works, and once you get used to it, it is even more dangerous than if it were never there!
Also let me point out that the newer electronics, unless especially designed for reliability, will not be more reliable than the old ones. One example is the number of rewrites in the consumer digital camera flash memories. The single cell endurance is much shorter now, and constant repairs have to be done to maintain the appearance of a "working" disk, for up to 3k-10k rewrites, depending on the vendor. I doubt the low budget glass cockpit designers can gather enough reliability data for their products before the next "upgrade" is necessary for their survival in the market place.
Many people know Microsoft stuff is not reliable, but there are other software that can be more unreliable. The glass cockpits for small airplanes will be among those.
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Continued on 5.940 Risk Management for Pilots