Chapter 1
Risk Management and Single-Pilot Resource Management
Introduction
āPull the throttle back!ā Lenore, a flight instructor, ordered the learner, Jennifer, as the revolutions per minute (rpm) climbed past past 2,000 on engine start. āI did, I did!ā
Both Jennifer and Lenore grabbed the mixture and pulled. The engine went from a deafening roar to silence. They looked at each other. āWhat happened?ā asked Jennifer. āI donāt know. Letās check the engine,ā Lenore said.
Ten minutes later, they had removed the cowling from the airplane. A quick engine check gave them the answer. The throttle rod-end was not connected to the carburetor armāno bolt, no nut, just air between the rod-end and the arm. Jennifer looked at Lenore. āWhat if this had happened in flight?ā
āWhat I want to know,ā Lenore said, āis how this happened at all. The annual inspection was signed off yesterday.ā
The previous day, the annual inspection had been signed off after a lengthy inspection by a local facility. Several mechanics had been involved in the inspection, including the owner/learner who had installed a headliner. The mechanic with the Inspection Authorization (IA) who signed off the annual was supervising several annuals, so most of the maintenance was performed by other mechanics.
After the inspection, the engine had been run-up according to the usual post-inspection procedures. The learner and instructor had flown the airplane for a half-hour familiarization flight. The next dayās engine start resulted in a runaway engine with the apparent cause due to the lack of the throttle rod-end hardware being safetied.
Three deficient areas in this annual inspection were identified by a round-table discussion group of aircraft and powerplant (A&P) mechanics and the learner. These areas were:
ā¢ Lack of responsibility
ā¢ Checklist misuse
ā¢ Complacency
Lack of responsibilityāno one took responsibility for the entire inspection. The chances of something being overlooked increase with an increase in the number of mechanics involved in an inspection. The responsible person is removed from the actual procedure. The learner remembers hearing the IA ask one of the engine mechanics about the throttle. However, the question was vague, the answer was vague, and the rod-end was not safetied.
Checklist misuseāPerhaps the throttle rod-end had been disconnected for maintenance after the IA had signed off the control inspection and marked that item as complete on the maintenance checklist. In that case, a discrepancy should have been entered onto the discrepancy sheet stating, āreconnect and safety throttle rod-end.ā
Complacencyāan insidious and hard-to-identify attitude. Each of the mechanics involved in the incident thought someone else had inspected the throttle rod-end. The IA signed off the annual inspection after asking the mechanics about the items on the checklist, making frequent visits to the airplane, inspecting some of the various items, and deciding that was good enough. Complacency crippled the mechanicsā quality of work by removing any thoughts of double-checking each otherās work.
While a definite answer to the question of what happened remains a matter of speculation, professional mechanics heed warning signs of potential problems. The combination of a lengthy inspection, numerous technicians, an overworked supervisor, a poor checklist, and vague communication raise a red flag of caution.
This scenario underscores the need for safety risk management at all levels of aviation. Safety risk management, a formal system of hazard identification, assessment, and mitigation, is essential in keeping risk at acceptable levels. Part of this process is selecting the appropriate controls to mitigate the risk of the identified hazard. The primary objective of risk management is accident prevention, which is achieved by proactively identifying, assessing, and eliminating or mitigating safety-related hazards to acceptable levels.
This chapter discusses safety risk management in the aviation community, looking at it as preemptive, rather than reactive. The principles of risk management and the tools for teaching risk management in the flight training environment are addressed in Chapter 9, Techniques of Flight Instruction.
Defining Risk Management
Risk is defined as the probability and possible severity of accident or loss from exposure to various hazards, including injury to people and loss of resources. [Figure 1-1] All Federal Aviation Administration (FAA) operations in the United States involve risk and benefit from decisions that include risk assessment and risk management. Risk management, a formalized way of thinking about these topics, is the logical process of weighing the potential costs of risks against the possible benefits of allowing those risks to stand uncontrolled.
Figure 1-1. Types of risk.
Risk management is a decision-making process designed to identify hazards systematically, assess the degree of risk, and determine the best course of action. Key terms are:
ā¢ Hazardāa 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, a nick in the propeller represents a hazard.
ā¢ Riskāthe 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 likelihood of loss (probability).
ā¢ Safetyāfreedom from those conditions that can cause death, injury, occupational illness, or damage to or loss of equipment or property, or damage to the environment. Note that absolute safety is not possible because complete freedom from all hazardous conditions is not possible. Therefore, safety is a relative term that implies a level of risk that is both perceived and accepted.
Principles of Risk Management
The goal of risk management is to proactively identify safety-related hazards and mitigate the associated risks. Risk management is an important component of decision-making. When a pilot follows good decision-making practices, the inherent risk in a flight is reduced or even eliminated. The ability to make good decisions is based upon direct or indirect experience and education. It is important to remember the four fundamental principles of risk management:
Accept No Unnecessary Risk
Unnecessary risk is that which carries no commensurate return in terms of benefits or opportunities. Everything involves risk. The most logical choices for accomplishing a flight are those that meet all requirements with the minimum acceptable risk. The corollary to this axiom is āaccept necessary riskā required to complete the flight or task successfully. Flying is impossible without risk, but unnecessary risk comes without a corresponding return. If flying a new airplane for the first time, a flight instructor might determine that the risk of making that flight in low instrument flight rules (IFR) conditions is unnecessary.
Make Risk Decisions at the Appropriate Level
Anyone can make a risk decision. However, risk decisions should be made by the person who can develop and implement risk controls. In a single-pilot situation, the pilot makes the decision to accept certain levels of risk, so why let anyone elseāsuch as ATC or your passengersāmake risk decisions for you? In the maintenance facility, an aviation maintenance technician (AMT) may need to elevate decisions to the next level in the chain of management upon determining that those controls available to him or her will not reduce residual risk to an acceptable level.
Accept Risk When Benefits Outweigh the Costs
All identified benefits should be compared against all identified costs. Even high-risk endeavors may be undertaken when there is clear knowledge that the sum of the benefits exceeds the sum of the costs. For example, in any flying activity, it is necessary to accept some degree of risk. A day with good weather, for example, is a much better time to fly an unfamiliar airplane for the first time than a day with low instrument flight rules (IFR) conditions.
Integrate Risk Management into Planning at All Levels
Risks are more easily assessed and managed in the early planning stages of a flight. Changes made later in the process of planning and executing may become more difficult, time consuming, and expensive. However, safety enhancement occurs at any time appropriate and effective risk management take place.
Risk Management Process
Risk management is a simple process which identifies operational hazards and takes reasonable measures to reduce risk to...