Risk Management - Aeronautical Decision Making

Risk management is a formalized way of dealing with hazards. It is the logical process of weighing the potential cost of risks from hazards against the possible benefits of allowing those risks from hazards to stand unmitigated. It is a decision-making process designed to identify hazards systematically, assess the degree of risk, and determine the best course of action. Once risks are identified, they must be assessed. The risk assessment determines the degree of risk (negligible, low, medium, or high) and whether the degree of risk is worth the outcome of the planned activity. If the degree of risk is “acceptable,” the planned activity may then be undertaken. Once the planned activity is started, consideration must then be given whether to continue. Pilots must have preplanned, viable alternatives available in the event the original flight cannot be accomplished as planned.

Two defining elements of risk management are hazard and risk.
  • A hazard is a present condition, event, object, or circumstance that could lead to or contribute to an unplanned or undesired event, such as an accident. It is a source of danger. For example, binding in the antitorque pedals represents a hazard.
  • Risk is the future impact of a hazard that is not controlled or eliminated. It is the possibility of loss or injury. The level of risk is measured by the number of people or resources affected (exposure), the extent of possible loss (severity), and the likelihood of loss (probability).

A hazard can be a real or perceived condition, event, or circumstance that a pilot encounters. Learning how to identify hazards, assess the degree of risk they pose, and determine the best course of action is an important element of a safe flight.

Four Risk Elements

During each flight, decisions must be made regarding events that involve interactions between the four risk elements—the pilot in command (PIC), the aircraft, the environment, and the operation. The decision-making process involves an evaluation of each of these risk elements to achieve an accurate perception of the flight situation. [Figure 1]

Helicopter flying
Figure 1. Risk elements to evaluate in decision-making

One of the most important decisions that a PIC must make is the go/no-go decision. Evaluating each of these risk elements can help a pilot decide whether a flight should be conducted or continued. In the following situations, the four risk elements and how they affect decision-making are evaluated.

Pilot—A pilot must continually make decisions about personal competency, condition of health, mental and emotional state, level of fatigue, and many other variables. A situation to consider: a pilot is called early in the morning to make a long flight. With only a few hours of sleep and congestion that indicates the possible onset of a cold, is that pilot safe to fly?

Aircraft—A pilot frequently bases decisions to fly on personal evaluations of the aircraft, such as its powerplant, performance, equipment, fuel state, or airworthiness. A situation to consider: en route to an oil rig an hour’s flight from shore, having just passed the shoreline, the pilot notices the oil temperature at the high end of the caution range. Should the pilot continue out to sea or return to the nearest suitable heliport/airport?

Environment—This encompasses many elements unrelated to the pilot or aircraft. It can include such factors as weather, ATC, navigational aids (NAVAID), terrain, takeoff and landing areas, and surrounding obstacles. Weather is one element that can change drastically over time and distance. A situation to consider: a pilot is ferrying a helicopter crosscountry and encounters unexpected low clouds and rain in an area of rising terrain. Does the pilot try to stay under them and scud run, or turn around, stay in the clear, and obtain current weather information?

External Pressures—The interaction between the pilot, the aircraft, and the environment is greatly influenced by the purpose of each flight operation. A 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. A situation to consider: a pilot is tasked to take some technicians into rugged mountains for a routine survey in marginal weather. Would it be preferable to wait for better conditions to ensure a safe flight? How would the priorities change if a pilot were tasked to search for cross-country skiers who had become lost in deep snow and radioed for help?

Assessing Risk

It is important for a pilot to learn how to assess risk. Before a pilot can begin to assess risk, he or she must first perceive the hazard and attendant risk(s). In aviation, experience, training, and education help a pilot learn how to spot hazards quickly and accurately. During flight training, the instructor should point out the hazards and attendant risks to help the student pilot learn to recognize them.

Once a hazard is identified, determining the probability and severity of an accident (level of risk associated with it) becomes the next step. For example, the hazard of binding in the antitorque pedals poses a risk only if the helicopter is flown. If the binding leads to a loss of directional control, the risk is high that it could cause catastrophic damage to the helicopter and the passengers. The pilot learns to identify hazards and how to deal with them when they are incorporated into the training program.

Every flight has hazards and some level of risk associated with it. It is critical that pilots be able to:
  • Differentiate, in advance, between a low-risk flight and a high-risk flight.
  • Establish a review process and develop risk mitigation strategies to address flights throughout that range.

Examining NTSB reports and other accident research can help a pilot to assess risk more effectively. For example, the accident rate decreases by nearly 50 percent once a pilot obtains 100 hours, and continues to decrease until the 1,000 hour level. The data suggest that for the first 500 hours, pilots flying visual flight rules (VFR) at night should establish higher personal limitations than are required by the regulations and, if applicable, apply instrument flying skills in this environment.

Individuals training to be helicopter pilots should remember that the helicopter accident rate is 30 percent higher than the accident rate for fixed-wing aircraft. While many factors contribute to this, students must recognize the small margin of error that exists for helicopter pilots in making critical decisions. In helicopters, certain emergency actions require immediate action by the pilot. In the event of an engine malfunction, failure to immediately lower the collective results in rotor decay and failed autorotation. Fixed wing pilots may have slightly more time to react and establish a controllable descent. According to the General Aviation Joint Steering Committee, the leading causes of accidents in GA are CFIT, weather, runway incursions, pilot decision-making, and loss of control. These causes are referred to as pilot-error, or human factors related, accidents. CFIT, runway incursions, and loss of control type accidents typically occur when the pilot makes a series of bad judgments, which leads to these events. For example, when the pilot has not adequately planned the flight and the pilot subsequently fails to maintain adequate situational awareness to avoid the terrain, a CFIT accident occurs.

While the reasons for individual helicopter incidents vary, it can be argued that it is the helicopter’s flight mode and operational complexity that directly contributes to each incident. By nature of its purpose, a helicopter usually flies closer to terrain than does a fixed-wing aircraft. Subsequently, minimal time exists to avoid CFIT, weather related, or loss of control type incidents that require quick and accurate assessments. Fixed-wing aircraft normally fly at higher altitudes, and are flown from prepared surface to prepared surface. Helicopters are often operated in smaller, confined area-type environments and require continuous pilot control. Helicopter pilots must be aware of what rotor wash can do when landing to a dusty area or prior to starting where lose debris may come in contact with the rotor blades.

Often, the loss of control occurs when the pilot exceeds design or established operating standards, and the resulting situation exceeds pilot capability to handle it successfully. The FAA generally accepts these occurrences as resulting from poor judgment. Likewise, most weather-related accidents are not a result of the weather per se but of a failure of the pilot to avoid a weather phenomenon for which the aircraft is not equipped, or the pilot is not trained to handle. That is, the pilot decides to fly or to continue into conditions beyond pilot capability, commonly considered bad judgment.

It cannot be emphasized enough that the helicopter’s unique capabilities come with increased risk. Since most helicopter operations are conducted by a single pilot, the workload is increased exponentially. Low-level maneuvering flight (a catch-all category for different types of flying close to terrain or obstacles, such as power line patrol, wildlife control, crop dusting, air taxiing, and maneuvering for landing after an instrument approach), is one of the largest single categories of fatal accidents.

Fatal accidents that occur during approach often happen at night or in instrument flight rules (IFR) conditions. Takeoff/ initial climb accidents are frequently due to the pilot’s lack of awareness of the effects of density altitude on aircraft performance or other improper takeoff planning that results in loss of control during or shortly after takeoff. One of the most lethal types of GA flying is attempting VFR flight into instrument meteorological conditions (IMC). Accidents involving poor weather decision-making account for about 4 percent of the total accidents but 14 percent of the fatal mishaps. While weather forecast information has been gradually improving, weather should remain a high priority for every pilot assessing risk.

Using the 3P Model To Form Good Safety Habits

As discussed in the Pilot’s Handbook of Aeronautical Knowledge, the Perceive, Process, Perform (3P) model helps a pilot assess and manage risk effectively in the real world. [Figure 2]

Helicopter flying
Figure 2. 3P Model

To use this model, the pilot will:
  • Perceive hazards
  • Process level of risk
  • Perform risk management

Let’s put this to use through a common scenario, involving a common task, such as a confined area approach. As is often the case, the continuous loop consists of several elements; each element must be addressed through the 3P process.

A utility helicopter pilot receives the task of flying four passengers into a remote area for a hunting expedition. The passengers have picked the location where they would like to be dropped off based on the likelihood of wildlife patterns for the area. The area has steep, rugged terrain in a series of valleys and canyons leading up to large mountains.

Upon arrival at the location, the pilot locates a somewhat large confined area near the base of one of the mountains. The pilot begins the 3P process by quickly noting (or perceiving) the hazards that affect the approach, landing, and takeoff. Through thorough assessment the pilot takes into consideration:
  • Current aircraft weight/power available,
  • Required approach angle to clear the trees for landing in the confined area,
  • Wind direction and velocity,
  • Limited approach and departure paths (due to constricting terrain),
  • Escape routes should the approach need to be terminated prior to landing,
  • Possible hazards, such as wires or structures either around the landing site or inside of the confined area, and
  • The condition of the terrain at the landing site. Mud, dust, and snow can be extreme hazards if the pilot is not properly trained to land in those particular conditions.

The pilot reviews the 3P process for each hazard. The pilot has perceived the risk associated for each of the bullets listed above. Now, the pilot assesses the risk level of each and what to do to manage or mitigate the risk.

The aircraft weight/power risk is assessed as low. While performing power checks, the pilot verified adequate out of ground effect (OGE) power exists. The pilot is also aware that, in this scenario, the departure DA (6,500 feet) is greater than the arrival location DA (6,000 feet) and that several hundred pounds of fuel have been burned off en route. Furthermore, once the passengers have disembarked, more power will be available for departure.

The pilot estimates that the highest obstacles along the approach path are 70–80 feet in height. With the size of the confined area, a normal approach angle can be maintained to clear these obstacles, giving this a low risk level. To further mitigate this risk the pilot has selected mental checkpoints along the approach path that will serve as go/no-go points should the pilot feel any assessed parameter is being exceeded.

Wind direction and velocity are assessed as a medium risk because (for this scenario) the direction of the wind is slightly offset from the chosen approach path, creating a 15–20° crosswind with a steady 10-knot wind. The pilot also takes into consideration that, due to the terrain, the wind direction and velocity may change during the approach. The pilot’s experience and awareness of the complexity of mountain flow wind provide a management tool for risk reduction.

From an approach and departure standpoint, the risk is assessed to be medium. There is only one viable approach and departure path. Given the size of the confined area and the wind direction, the approach and departure path is deemed acceptable.

The pilot assigns a medium risk level to the selection of an escape route. The pilot is aware of the constricting terrain on either side. Although adequate area exists for maneuvering, the pilot realizes there are physical boundaries and that they can affect the options available should the pilot need to conduct a go-around or abort the approach. Again, the pilot uses mental checkpoints to ensure an early decision is made to conduct a go-around, if needed. The selected go-around or escape route will be in line with the selected approach/departure path and generally into the wind.

As you may have noticed, one identified hazard and its correlating risk management action may have subsequent impact on other factors. This demonstrates the need for continuous assessment and evaluation of the impact of chosen courses of action.

The 3P model offers three good reasons for its use. First, it is fairly simple to remember. Second, it offers a structured, efficient, and systematic way to identify hazards, assess risk, and implement effective risk controls. Third, practicing risk management needs to be as automatic as basic aircraft control. As is true for other flying skills, risk management thinking habits are best developed through repetition and consistent adherence to specific procedures.

Once the pilot completes the 3P decision process and selects a course of action, the process begins anew as the set of circumstances brought about by the selected course of action requires new analysis. Thus, the decision-making process is a continuous loop of perceiving, processing, and performing.