John’s blog: risk management is a sham

Quick quiz: what’s The Next Big Thing in aviation safety right now? You know, the supposedly ground-breaking new idea that is being relentlessly promoted by the aviation intelligentsia? If you answered runway incursions or aeronautical decision making, you are hopelessly out of date.

The correct answer, and the current miracle cure for aviation, is Risk Management. Read enough magazines or attend an FAA safety seminar and you will undoubtedly be lectured about the values of the “PAVE checklist,” the “3P model” or the the “risk assessment matrix.” Through a simple mnemonic and a quick math problem, we’re told, you can virtually eliminate your chances of being in an accident.

Bonanza crash site
Is it a failure of the PAVE risk management checklist, or maybe just a crash?

I, for one, am tired of all this nonsense. Risk Management in its current form is a sham, a feel-good phrase that is popular precisely because its meaning is so elastic. Just like “I want better schools” and “I support a strong America,” everyone is in favor of it until it comes time to define what it actually means and how to do it.

Don’t get me wrong–I’m not against risk management, per se. Whether you’re operating a nuclear power plant or a Cherokee, identifying potential hazards and weighing the pros and cons of different actions makes sense. But what is being presented as The Next Big Thing is in fact a basic concept that flight instructors have been teaching for decades (this very publication was talking about it in the 1950s). It’s an attempt to sensationalize the obvious.

As you would expect, a cottage industry of safety entrepreneurs has sprung up to take advantage of the trend. And they’re promoting a list of serious-sounding proposals, complete with fancy names. Most prominently, there is the campaign for Safety Management Systems (SMS). This formalized process attempts to identify and manage risks from the top down, but succeeds mostly at creating a pile of paperwork. One important element of these SMS programs is the Flight Risk Assessment Tool (FRAT), which is unfortunately a safety equation, not a place to have a party.

Through the use of tools like the FRAT, the Risk Management experts are trying to fundamentally change how pilots think about pre-flight planning, weather briefings and a whole lot more. It’s an attempt to turn the thoughtful, deliberate act of aeronautical decision making into a mathematical formula–and remove the human brain from the process.

Call it the triumph of the math majors over the history majors, or the left brain over the right brain. No matter what the reason, the trend toward more math and less “gut feel” is changing plenty of fields besides aviation. Take finance: whereas once traders decided to move based on market news and a sense of timing, they now make trades based largely on what their algorithms say.

The FRAT is this mentality applied to aviation. The document attempts to assess a variety of potential hazards for each flight, from pilot currency to weather to airport conditions. No bad thing, but as usual the devil is in the details. A model document from the FAA suggests scoring each line, usually from 1 to 5. For example, a single pilot flight warrants a risk value of 5. That may be the case if you are flying a jet and you usually fly as a crew. But what if you’re in a 172 and all of your time is single pilot? Do you ignore the supposed risk or change the risk value? Either way is a slippery slope. In essence, you get to both make up the test and grade the test.

Flight Risk Assessment Tool
The formula for safety? The Flight Risk Assessment Tool (from FltPlan.com).

The obvious problem with this simplistic matrix is that risk, especially in aviation, is a frustratingly complicated and ever-changing thing. Identifying hazards and mitigating risk takes intuition, experience and an appetite for ruthless self-criticism. A formula or a checklist can’t possibly encapsulate all of the factors that add risk. If you don’t believe me, just ask the folks at Lehman Brothers how their sophisticated risk model worked out when the credit crisis hit.

But tools like FRAT are worse than just unhelpful. I think they also take some of the fun and challenge out of flying. Managing risks is what flying (and life, for that matter) is all about; it’s what makes being a pilot so rewarding. Replacing that with a formula not only oversimplifies things, it makes a fun experience just another box to check. This is not to mention the serious turn-off this is for a prospective pilot. Can you imagine sitting down with a brand new student to go over a FRAT?

Maybe there’s an argument to be made that an airline needs an SMS, as a way to standardize decision-making and avoid a rogue pilot jeopardizing the company. But that’s not the case for a Cirrus owner, where decision-making is much more personal and the flight department is one person. One size does not fit all when it comes to safety, and even the FAA recognizes this. The FARs give Part 91 operators more leeway with equipment failures, weather minima and maintenance; we should recognize that same distinction when it comes to SMSs.

I’m not suggesting we shouldn’t consider the risks before a flight. And I’m also not advocating we ignore risk management during primary training. But the idea that some lengthy matrix or mnemonic can dramatically improve safety is naive. Let’s do the harder–but much more important–job of teaching real world decision-making, every time we fly.

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23 Comments

  • I understand where the writer is coming from, I’m in the US Army and we have a million risk matrices for everything from my personal life and whether I’m a risk based on my mood, extracurricular activities (i.e. sports, hobbies, alcohol, traveling, etc). Of course we have risk matrix for every time we want to take more than two days off, or each and every 4-day holiday or when we want to take leave…even if I had told my command that I have no intention on leave HOME! I’m a very reliable person, never gotten in trouble in the 10 years I’ve been in the Army, or gotten hurt other than a serious traffic incident relating to black ice. I don’t get anything from these risk matrices, at all.

    BUT! I’m a supervisor of children, or so it seems sometimes. These kids need or even some of the older ones need to be reminded of the pitfalls and dangers with their behavior or activities. Will the risk matrix ultimately stop him from drinking and driving over the 4-day weekend, probably not. But for some, it may remind them that they are a higher risk. As you get into actual flight missions, those matrices play a bigger part, and have prevented numerous accidents or incidents from taking place by reminding the pilots that they are in no shape to fly or to take extra precaution due to their more dangerous environment, aircraft that may have known deficiencies, or pilots that may not have the full 8-12 hours of rest each day, or combat conditions.

    How does this translate to civilian pilots, more specifically private pilots…it may not translate for some who take precautions on each and every flight. But for some, they may need it as another form of checks and balances.

    Carrying wife and kids on a xc flight.

    1. Has the PIC had a full 8-12 hours of sleep/rest?
    2. What is the conditions of weather, VFR, MVFR, IFR (VMC/IMC)?
    3. How many hours TT does PIC have?
    4. How many hours Time on Type/Model does PIC have?
    5. Have you consumed any alcohol in the past 12 hours?

    ETC, ETC, ETC.

    Then it of course factors in the risks inherent with each answer to the question and then gives you the overall risk, and based on the risk you can either proceed or add that to your deliberation on whether it’s safe enough to fly your family. How many times have we seen people fly into the side of a mountain or crashed during IMC. Pilot is only rated VFR but took off in MVFR conditions only to get caught in IMC. There are stupid pilots out there, there are stupid people out there and some need a little extra help, someone to help watch over their shoulder to remind them that they are about to make a very deadly mistake. Risk matrix will not prevent you from doing it anyway, but at least you will have a better idea of whether what you’re about to do is riskier than usual.

    That’s just my two cents.

    • I strongly disagree that people need “someone to watch over their shoulder to remind them that they are about to make a very deadly mistake”. The very opposite of this is what makes a free society! We have the freedom to make the choices that we want, and if it’s dangerous, or if we have a higher tolerance of risk than someone else, then so be it because in a free society that is our choice! We don’t need someone to tell us what is our responsibility to know. If someone freely chooses to conduct a formal risk assessment, then that’s fine and it can be a useful tool for some. But in America we should never be requiring private individuals to conduct these assessments, but that’s clearly the way it is heading.

      • Thats the kind of attitude that gets people killed because they made a mistake because they were too good to read the checklist before they went out to fly, which could have prevented the deaths of friends, family and those who trusted that pilot to make the right decision.

        You want to be free, be free elsewhere. I’m not interested in getting in a midair collision with some who thinks he’s not free if someone has to remind him to watch for other traffic as he barrels through the traffic pattern or when he ignores ATC because he’s just another government official ‘keeping the man down’.

        You don’t believe in a risk assessment as a PP, fine. But don’t say that’s our society is becoming less free because someone wants to ensure you’re making the right decision or reminding of you that it may not be logical for you to fly that day. I’m trained as an Army’s version of an NTSB Investigator. As part of my training I read hundreds of reports, civilian, commercial, military and wonder how many times it’s been due to PILOT ERROR, not due to faulty equipment, avionics, weather or airframe which ends up related to PILOT ERROR in the end anyway.

        You think you’re a big boy and wear your big boy pants, then grow up! We don’t need to hear your OCCUPY General Aviation attitude. This isn’t a conspiracy to take your freedoms. You can thank your fellow pilots who have fallen asleep, flew while under the influence, flew into IMC as a VFR pilot, or someone who thinks its a wise decision to pull the yoke back during a stall.

        • We definitely have different views of personal responsibility if you believe that the desire to not be watched over or told what to do, is equivalent to not wanting to run a checklist or conduct a risk assessment. Risk assessment is what live pilots have been doing on their own forever, though not necessarily on paper and certainly not shared with regulating authorities. (If a pilot isn’t taking stock of the hazards and risks, he won’t be a live pilot for long.). Now as we move towards requiring all operators, even private operators, to formally conduct these assessments, we are adding yet another intrusion into our privacy.

          By the way, if someone wants to fly after pounding a few shots of Tequila, do you think that will be a category to select on a risk assessment? Do you think they will honestly answer that? If someone isn’t willing to take personal responsibility for the safety of their flight, no other entity can do that for them.

  • Good examples, Tim. I don’t think Risk Management is a sham. The numerous memory aids and decision tables make me weary as well, but my regional airline doesn’t use any of those. We are developing an SMS though, and management emphasizes TEM (Threat Error Management), which is making our pilots more engaged in risk management.
    Getting pilots more involved in risk management will ultimately improve flight safety as a whole.
    I see these tools as devices to assist non-professional pilots in making no-go and divert decisions in the interest of safety. IMO too many GA pilots still let their business or personal priorities and/or ego-pride override their experience and ability levels, moreso with new generation avionics onboard. Emphasizing risk management by teaching these tools will pay off, in spite of the over the top appearance they can have to professional pilots. If the math based assessment devices don’t appeal to a pilot, they could establish a checklist item to evaluate the risk at each stage of a flight by their own methods. This is much what Pro pilots do in any case. Vocational pilots sometimes don’t see the forest for the trees,regarding risk management, but that is understandable, considering their arena, workload, & experience levels.

    • Craig, I agree to a certain extent with both you and Tim. For an airline or military operation, standardization is everything, and I can see some benefit to a structured risk management program. But I don’t see it for the average GA pilot. There is no safety officer, no dispatchers, no flight department. It’s all on the pilot, and I don’t think another checklist or a math problem will help.

  • Risk Management is only as effective as the person re ognizing and evaluating the hazard. It can be very effective at managing your bottom line costs and protecting your reputation. I have been involved in some aspect of risk management for over 15 years….and I love to fly.

  • I think most of initial aviation training is too hooked on phonics…I mean mnemonics. It’s an easy way to learn the regs, but it doesn’t ingrain the concept, and the pilot candidate gets too engrossed in learning the acronym or the mnemonic (which in itself can be extremely confusing), versus learning the principle involved.

    Marc

  • I believe that this is simply another way to think about risk. If it helps you then use it. If it doesn’t, then find something else that does. It’s a tool.

    One way to think about risk is in terms of outcomes. Die … Get there on time … Don’t get there or get there late … Get there but scare crap out of self, etc. if you think about those things as the outcomes, risk is the uncertainty associated with a particular outcome (usually in flying, get there on time and safely is the outcome we start from.)

    If that is what risk is, then weather, icing, Terrain, etc. are all Risk Contributors. We often call them risks for short, but they aren’t the uncertainty itself, they rather are contributors to uncertainty. the risk s the overall uncertainty in the desired outcome.

    I explain this because this little framework allows us to clean up our conceptual thinking about risk. Try it next time, just a bit of a thought exercise. For me, it helps.

    • Agreed, SMS or FRAT is another tool available. Use it or don’t use it as you see fit. The problem comes when we are required to use it by the authorities for our own private flying. If an airline wants to implement the program, that is their business. If you or I want to implement the program in our personal flying, that’s our business. But don’t force me to get government approval before I take off in my own airplane. It’s a slippery slope; we’re already required to get permission to LEAVE the country in our own airplanes with the eApis system.

  • What is safety? While you look up the definition I’ll tell a story.

    I’ve been under the thumb of USAF and Civil Air patrol safety empires. Some are good, some are absurd. The best are reasonable, knowledgeable people who share strategies, tactics and procedures and we called it training. The best rule of thumb is no more than three of anything: We all forget the fourth, so why bother. The USN has an even simpler one: Two screw-ups and consider aborting: You are not in the game.

    The worst are the grad students and bureaucrats who hold a job and are going to make the best of it. I find it unpleasant to have non-pilot staff weenies tell me what is safe and not safe about flying. I’ve had know-nothings spout well-memorized pace/spans/blah blah stuff and lose track of why we were about to do what we were about to do. “‘Safety’ is paramount and shall not be infringed” claims the new lieutenant. ‘Let me buy you a beer and explain life’ said the Colonel.

    I’ve also been an involuntary member of a few safety boards. When all the bureaucrats were done testifying about the broken rule or ignored warning, we exonerated the evil-doer for exercising his or her role as PIC and praised a can-do attitude. Probably all mortal sins against numerous gods today.

    So what is safety? According to the Safety and systems school at USC, it’s a way of reducing the cost of doing business. Insurance is a way of reducing the immediate cost, but inscos often require proof of training, so why not skip the middle man and put that money toward more training?

    What to train? Simple: What are the best-known stupid pilot tricks? My top three are: Running out of gas; hitting things and flying into weather you cannot handle, to include crosswind landings.

    And just to start another fight is my position on GA fatalities: Stuff happens: Exactly why some self-appointed hallway monitors think GA can be an idiot-free zone is unclear to me when actuarial data shows it to be a safe activity compared to various combinations of motor vehicles, smoking, falls, firearms and alcohol.

  • This discussion of risk management is fascinating philosophically. Our culture tends to proceduralize knowledge, and then acts as if such proceduralized knowledge is better than the intuition and experience that developed the procedures in the first place. Michael Polanyi, a chemist and philosopher, argued that all knowledge has its basis in personal knowledge, and that personal knowledge is not just in our heads, that is, our brains, but in our bodies, as well. As an example, sometimes it is easier to remember a phone number if you fake dial it on a fake keypad. Moving our fingers the way we do to dial the number helps us remember it. So a GA pilot, like myself, who has many hours of flying in IFR conditions all year long in the southeast, knows more than I can say about the go/no-go of any flight. I might be able to proceduralize such knowledge, but sometimes I just know this is a trip I could do, but I am going to wait for conditions to change and improve. I can’t always articulate my reasons, but that does not mean my reasons are unreasonable or suspect, merely that I know more than I can say about flying. The proceduralized knowledge developed in various risk management matrices can be an aid to those who have not yet developed the personal knowledge that comes through varied experiences. It is one way for others to learn from our experiences. However, the proceduralized knowledge is always secondary to the personal knowledge that developed the procedures. The fancy math of risk management matrices is dependent on personal knowledge, not superior to it. Ain’t flying fun–you get to be up in the air and philosophize about it as well.

  • I’d rather not see politics get wrapped up in this too much. However, the facts are that the manufacturers, the insurers, the alphabet groups, and GA as a whole have a vested interest to lower the “pilot error” accident rate, and it seems the industry is backing these new risk management tools.
    Think of the pilot that has the new plane with new glass, confidence & capability, but not much experience. At the end of a long day with weather, they might not have much aeronautical decision making/risk management capability left, because they are too consumed with just flying the plane single pilot IFR or marginal VFR – too focused on just flying to busy to make a no-go or divert decision. These tools address those shortcomings, and some, not all, GA pilots will utilize them. Even some pilots using them makes these new risk management techniques worthwhile, imo.

  • Craig, you’re right about politics–we have enough of that and it’s not my intention to get into that debate. But I think some of this debate comes down to “available tool” vs. “forced to use it.” I certainly don’t think the FRAT will kill anybody, I just think it’s ineffectual. But if someone wants to use it, that’s fine. My issue is either a) putting too much stock in it, or b) being forced to use it. We’re required to take off with adequate fuel, and plenty of people find ways to run out of it every year.

    • Well I completely agree that part of the freedom of being a pilot in the United States includes not being forced to use the latest risk management tool. IF the FAA ever mandates that or when legislation gets introduced that requires pilots to do that, call me and we will go complain in person!

  • To analyze risk is to enjoin safe aviation practices.
    Being able to see beforehand safety issues forward allows us to make informed decisions and hence, be safe and safer as we operate.
    General Aviation Pilots are often not vested with many thousands of hours of flying and operating time in their ship or in the ATC. Therefore, reading and assimilating the experiences and wisdom of others is to vicariously become experienced.
    The gut feelings we experience as we operate come from an inner sense of situational awareness brought upon us via mental imaging.
    Creating our experience level by any means available safe and secure, is to become wise and safe. Reading, flying and the natural hangar flying we all do, here and now, me doing so, is instrumental and fun, a way to become always safer in the air.
    Las Vegas Dave – Atlas Air Cargo, B-747 Flight Engineer, First Officer.

  • FRAT is a good guide to being safe.
    It is not a cure to all in flying, but a good tool at arriving at one’s plane to operate it in a safe and efficient manner.
    Analysis of all the issues in the FRAT check list cannot do any aviator harm.
    Las Vegas Dave

  • I’ve flown with Safety Pilots and had good flights; I’ve flown with Safety Pilots and had bad experiences as they ‘helped’ me tune radios, program the GPS, set up for the approach, etc. So I would rank Single Pilot as 1 (unless Zero is a choice), and Two-Man Crew as whatever the highest possible value is.

    Oops, just destroyed the one-size-fits-no one, pre-approved, committee-made FRAT checklist. And yes, I have the same pre-flight conversations, so there goes your excuse of how I screwed it up before the first takeoff.

    If things like this are ever required, not only will enforcement only happen after the fact (it’s not educational adding it up after having problems, nor will it prevent poor flight choices today if I do it tomorrow) but many non-corporate, non-airline pilots will simply run off some copies to carry around, much like the W&B spreadsheet I made as a learning exercise after buying my plane.

    It’s easy to be a good quarterback on Monday morning, but post-game analysis can only help you win the next game, not the one you’re in right now. I know me and my plane, and I study weather and route then make the call: go, stay, wait or deviate. Will FRAT help me plot a route around icing, or find the lowest MEAs through the hills? Will it point out active MOAs and R-space? Didn’t think so. Therefore I, the Pilot In Command, Mr. Johnny-on-the-Spot, have to think for myself and decide many things starting with Go/No-Go and ending with when to turn final, how much crosswind correction to use and when to pull the throttle to idle. Or should I be filling out another form to tell me when to do those, too? Rules are rules, checklists are CHECKlists not DOlists, and there is no replacement for thinking.

  • Just read this on a real computer instead of my phone, and can actually see the FRAT checklist.

    My plane does not have a Captain or a First Officer, there is only the PIC [me]. I have never flown 100 hours in 90 days. I frequently visit airports with no published instrument approaches; I also visit places where there is either no approach with vertical guidance or only GPS approach(es) with vertical guidance.

    Never realized how risky my flying is! But both my CFI and my CFII trained my to fly single-pilot, to visit non-towered fields, to visit grass fields and to land without an instrument approach, without vertical guidance and even (gasp!) without glideslope or even approach lighting.

    Some things just don’t translate well from the rarified world of the airlines to the single-piston world we live in. Or should I maintain a sterile cockpit below 10,000′, never speaking a word to any of my passengers nor allowing them to speak to me, ever, since I have only cruised at 10,000 msl once and not above that yet? That’s as meaningful of a suggestion as limiting my speed to 250 knots below 10,000′, a speed my plane will reach only in a vertical dive after the wings break off.

    Can you say impractical? Can you say “will be ignored”? Can you say Irrelevant?

    Do you want to do something meaningful? Don’t push the airline mantra onto us without revising it to fit. Full fuel for me represents 12% of gross, so keeping my Golden Hour in reserve my weight change from takeoff to landing will never exceed 10% of gross. Airliners frequently carry 40% or more of their takeoff weight in fuel. Bet they have to worry about CG and stall speed changes; I don’t.

    “Recent experience for the First Officer” will never be an issue for the bulk of GA planes, because there is no such person. Generally I ignore irrelevant stuff like this, but since it is being pushed by the NTSB & FAA, it is either speak up or deal with it forever. If there must be a formal system, make it relevant. Best is to not have a formal system. Isn’t this covered during PPL training? It is also covered in Instrument training. It is supposed to be covered again during mandated Flight Reviews. It is covered in many of the FAA Wings programs that are offered as alternatives to Flight Reviews.

    Or is having a piece of paper with check marks for things that don’t apply supposed to increase safety?

  • THANK YOU, THANK YOU, THANK YOU. You articulated what I have been thinking ever since I first heard of SMS. This seems to me to just be thought up and promoted by some bureaucrat(s) hoping to impress people or secure their position. Probably both.

  • I totally agree with John Collins on this one. I too am an airline pilot and have the pleasure of the ABC’s of TEM. Maybe I am old school where I think my experience is worth something. What I see instead is the writing of scripts for every conceivable problem. It is an attempt to keep the pilot from thinking. Management would far rather you follow the script to the point that you fly around for 2 and a half hours doing endless checklists with an engine on fire before landing the airplane. I do not like trouble shooting in the air. If I have a flight control problem, an engine problem, my primary job is to get that airplane safely on the ground as soon as possible. Two and a half hours running checklists does not sound like ASAP to me. The truth of the matter is that FAR 91 gives pilots a lot of room to maneuver. In that freedom, risks abound. How you handle them is up to you.

  • Wow, A lot of really good thoughts from all of the previous posts. As a company owner and pilot involved in flying for directing aerial fire suppression, I see a great number of unique circumstances develop in a highly dynamic environment where wild land fire meets aviation.
    Perhaps the most poignant point is that while we are flying with our own risk management in the aircraft, the fire fighters on the ground are working their own risk management that derives from some well formalized side boards in the way of slowly and painfully developed (read, burned fire fighters) rules for engagement, and when and how to disengage. Few environments offer such a mix of demands on all those involved, to deal with risks and maintain functionality.
    As was well stated by several previous commenters; the Risk Management Matrixes are lacking in several ways if used in a sterile manner. The key element that is fundamental to any decision making is “ how does it feel” to the pilot, what ever “it” is; a risk factor, and was better defined as stated previously by a blog conributor as “it being an identified “Contributor” to total risk. We look at a risk management matrix and we do not see any opportunity for “how does it feel” . The feeling of fear is telling you something that is important to listen to. Example: That one item on the Risk Matrix Table was only a 2 point plus for risk factor, however, if you are honest with how it feels looking at it, you would circle it and make it bold. In fact, you would put a multiplier on it that was times 4 and that might not be enough. Why is it bothering you, scaring you so much? Do you know, can you quantify it ? Do you have to quantify it !!! So do so, and make it big and bold, and realize that though you can’t fully justify it with facts, you don’t need to; you simply have a feeling and you should acknowledge that and put the big bold underline and circle on it. This is the one “contributing factor” that is really the one that you feel might kill you. Think of the movie “Dirty Harry” Clint Eastwood tells the assailant as he lays on the ground with a gun within his prone reach, “now in all the ruckus, I don’t remember whether I fired my gun 5 or 6 times, so what you have to ask yourself is, do you feel lucky punk ? well do you “? And I guess that in essence ultimately, if we as a pilot encounter a decision that requires us to ask that question, it is definiately time to consider our circumstance carefully. I have always offered to my flying students a firm belief that alcohol is probably one of the best safety tools in the weather planning tool box. If you are encountered with an uncomfortable decision of whether to go or not based on weather conditions, have a big drink of your favorite or immediately available alcohol containing libation, and your decision can now be delayed at least 8 hours, where in the conditions in the atmosphere will likely have clarified themselves.

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