NTSB Safety Alert SA-023 - Pilots Manage Risks to Ensure Safety

Pilots: Manage Risks to Ensure Safety

Good decision -making and risk management

practices can help prevent accidents

The problem

 Although f ew pilots knowingly accept severe risks, accidents can also result when

several risks of marginal severity are not identified or are ineffectively managed by

the pilot and compound into a dangerous situation . Accidents also result when the

pilot does not accurately perceive situations that involve high levels of risk.

 Ineffective risk management or poor aeronautical decision -making can be associated

with almost any type of fatal accident across all general aviation (GA) sectors .1

Related accidents

Sadly, the circumstances of each new accident are often remarkably similar to those of

previous accidents. This suggests that some pilots are not taking advantage of the lessons

learned from such tragedies that could help them avoid making the same mistakes . The

following accident summaries2 provide examples of some common —and preventable —

accident scenarios related to ineffective risk management :

 A private pilot (who did not hold an instrument rating) and his three passengers were

killed after the pilot experienced spatial disorientation and lost control of a Cirrus

SR20 airplane in instrument meteorological conditions (IMC) . The pilot had attempted

a descent toward an airport that was reporting IMC, but he could not find it and told

the air traffic cont roller that he was flying “in and out of the clouds.” After the

controller learned that the pilot was not qualified for flight in IMC, another controller

advised the pilot of several nearby airports that were reporting visual weather

conditions. The pilot initially indicat ed that he would divert to one of those airports but

1 Each year, the NTSB investigates about 1,500 GA accidents in which about 475 people are killed . See the

NTSB data for Review of US Civil Aviation Accidents, Calendar Year 2011 , which can be accessed from the

NTSB’s Aviation Statistics web page at http://www.ntsb.gov/investigations/data/Pages/aviation_stats.aspx .

2 The accident reports for each accident referenced in this safety alert are accessible by NTSB accident

number from the NTSB’s Aviation Accident Database & Synopses web page at

http://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx . (The accident numbers are CEN12FA083 ,

CEN10FA071 , and WPR11FA03 2, respectively.) Each accident’s public docket is accessible from the NTSB’s

Docket Management System web page at http://www.ntsb.gov/investigations/SitePages/dms.aspx .

SA-023 March 2013 , revised December 2015

then c hanged his mind. Shortly after the pilot’s last communication with controllers ,

the airplane entered a right turn that tightened abruptly before the airplane

descen ded to the groun d in a steep, nose -down attitude .

 A pilot in a Cessna 310R airplane was killed when his airplane collided with terrain

during his second attempt ed approach to a familiar airport in night IMC with fog . The

pilot’s personal medical records noted a long histo ry of s evere migraine headaches ,

and his toxicology results were positive for several potentially impairing medications .

The pilot had not reported any medications or severe headaches to the F ederal

Aviation Administration (F AA) on his medical certificate application . The investigation

found that the pilot was likely impaired due to a migraine headache, medication use,

or both and that this impairment played a role in his decision to descend below a safe

altitude .

 A pilot and his three sons were killed when he lost control of his Mooney M20J

airplane , which collided with mountain ous terrain in a rapid descent . Before the flight,

the pilot had obtained weather briefings that included advisories for mountain

obscuration, turbulence, and icing. The pilot ha d previously canceled his plans to fly

the trip (the purpose of which was to return home from vacation) due to adverse

weather conditions , and he had made alternate arrangements for himself and his

sons to travel home on a commercial airline . However, when the airline flight was

canceled (for non -weather reasons ), the pilot decided to depart on the accident flight .

The pilot’s decision to depart into known adverse weather was a cause of the

accident . The investigation identified several safety issues, including evidence that

the pilot’s self -imposed time pressure adversely affected several safety aspects .

What can pilots do?

 Develop good decision -making practices that will allow you to i dentify personal

attitudes that are hazardous to safe flying, apply behavior modification techniques,

recognize and cope with stress, and effectively use all resources. Understand the

safety hazards associated with human fatigue and strive to eliminate fatigue

contributors in your life.

 Understand that effective risk management takes practice. It is a decision -making

process by which you can systematically identify hazards, assess the degree of risk,

and determine the best course of action.

 Be honest with yourself and your passengers ab out your skill level and proficiency.

Refuse to allow external pressures , such as the desire to save time or money or the

fear of disappointing passengers, to influence you to attempt or continue a flight in

conditions in which you are not comfortable.

 Be honest with yourself and the FAA about your medical condition. If you have a

medical condition or are taking any medication, do not fly until your fitness for flight

has been thoroughly evaluated.

SA-023 March 2013 , revised December 2015

 Plan ahead with flight diversion or cancellation alternati ves, and brief your

passengers about the alternatives before the flight.

Interested in more information?

Education and training are essential to improving GA safety. The Federal Aviation

Administration (FAA) Safety Team (FAASTeam ) provides access to online training courses ,

seminars , and webinars as part of the FAA’s “WINGS —Pilot Proficiency Program,” which

includes targeted flight training designed to help pilots develop the knowledge and skills

needed to achieve flight proficiency and to assess and mitigate the risks associated with the

most common causes of accidents. The courses listed below and others (many of which

were developed by the Aircraft Owners and Pilots Association [AOPA] Air Safety Institute, a

division of AOPA Foundation) , as well as seminar and webinar information, can be

accessed from the FAASTeam website at www.faasafety.gov . (Course access requires login

through an existing or creation of a free FAASTeam account .)

 Aeronautical Decision -Making for VFR Pilots

 Do The Right Thing: Decision -Making for Pilots

 The Art of Aeronautical Decision -Making

 Top 10 Causes of General Aviation Accidents

 Fatigue Countermeasure Training

Other resources:

 The AOPA Air Safety Institute offers several interactive courses, presentations,

publications, and other safety resources that can be accessed from its website at

http://www.aopa.org/Pilot -Resou rces/Air -Safety -Institute . (Course access requires

creation of a free account .) Examples include an accident case study, “In Too Deep ,”

that features the Cirrus SR20 accident summarized in this safety alert, and a video,

“Critical Information: The P assenger Safety Briefing ,” which provides information

about passenger safety briefings. A printable safety briefing card is included.

 Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083 -25A) discusses

aeronautical decision -making and risk management in chapter 17 . It provides basic

tools (including the “IMSAFE” health evalu ation, the “DECIDE” process for

aeronautical decision -making, and other tools) to help pilots assess risk and manage

it in a positive manner. The Risk Management Handbook (FAA-H-8083 -2) provides a

more in-depth discussion of risk management principles. Both handbooks can be

accessed from the FAA’s website at www.faa.gov.

 A Personal Minimums Checklist (based on the “PAVE” model) that you can print and

tailor to your skill level can be accessed from the FAA’s Guidance and Documents

website at www.faa.go v/training_testing/training/fits/guidance/ .

This NTSB safety alert and others can be accessed from the NTSB’s Safety Alerts web

page at http://www.ntsb.gov/safety/safety -alerts/Pag es/default.aspx .