AERONAUTICAL DECISION MAKING + SINGLE PILOT RESOURCE MANAGEMENT = OPERATIONAL RISK MANAGEMENT

1. AERONAUTICAL DECISION MAKING+SINGLE PILOT RESOURCE MANAGEMENT=OPERATIONAL RISK MANAGEMENT

2. CGAP Decision Making/Risk Management Definitions • Aeronautical Decision Making (ADM): systematic approach to consistently determine the best course of action to a given set of circumstances • Automation Management (AM): demonstrated ability to control and navigate an aircraft by means of the automated systems installed in the aircraft • Operational Risk Management (ORM): decision-making tool to systematically help identify operational risks and benefits and determine the best courses of action for any given situation. • Single Pilot Resource Management (SRM): art and science of managing all the resources (onboard aircraft and outside sources) available to a single pilot (prior to and during flight) to ensure the successful outcome of the flight is never in doubt. • Situational Awareness (SA): the accurate perception and understanding of all factors and conditions within the four fundamental risk elements (pilot, aircraft, environmental, external pressures) that affect safety before, during and after the flight. • Task Management (TM): process by which pilots manage the many concurrent tasks that must be performed to safely and efficiently fly a modern aircraft.

3. CGAP Decision Making/Risk Management Acronyms • AOE: Areas of Evaluation • CFIT: Controlled Flight Into Terrain • D-E-C-I-D-E: Detect-Estimate-Choose-Identify-Do-Evaluate • I-A-D-E: Identify-Analyze-Decide-Execute • I-A-A-D-E: Identify-Analyze-Assess-Decide-Execute • IFR: Instrument Flight Rules • IMC: Instrument Meteorological Conditions • I-M-S-A-F-E: Illness-Medication-Stress-Alcohol & drugs-Fatigue-Eating • MEA: Minimum Enroute Altitude • P-A-V-E: Pilot In Command-Aircraft-enVironment-External Pressures • T-E-A-M: Transfer-Eliminate-Accept-Mitigate

4. CGAP Decision Making/Risk Management "Tools" • The following Risk Management/Decision Making "Tools" are FAA AOE's for future pilot certification tests: - SRM - ADM - ORM - TM - CFIT Awareness • CGAP has incorporated some of these "tools" in its Decision Making/Risk Management Model - ADM/SRM/ORM Using versions of or the actual "tools" below: D-E-C-I-D-E; PPP's, 5P's, PAVE, I-M-S-A-F-E, T-E-A-M How does it all fit together?

5. CGAP Decision Making/Risk Management TREE

6. CGAP Aeronautical Decision Making: "I-A-D-E Loop"

7. CGAP Decision Making/Risk Management TREE

8. CGAP Decision Making/Risk Management: SRM & "5P's"

9. SRM and the "5P's" "5P's"- a scheduled review at key points in the flight where decisions are most likely to be effective: - pre-flight - before takeoff - midpoint cruise - before descent - before initial approach segment or pattern entry - anytime an emergency or abnormal situation occurs • PLAN- mission or task: weather, route, fuel, publications, ATC, nature of flight • PLANE- status/condition: mechanical, database currency, automation, backup systems • PILOT: I-M-S-A-F-E Illness: symptoms, do I feel well?Medication: am I taking medication which is not approved for flying?Stress: am I under emotional stress or psychological pressure? Are there personal distractions?Alcohol & drugs: have I consumed alcohol within the last 8, 12, 0r 24 hours; do I use controlled substances?Fatigue: have I had sufficient rest; am I sleepy? Eating: am I adequately nourished; do I have too low a blood sugar level or too high a caffein level?

10. SRM and the "5P's" "5P's"- continued • PASSENGERS- pilot, non-pilot, experienced vs nervous flyer, quiet vs disruptive • PROGRAMMING- avionic, navigation management systems, flight control systems, EFIS, powerplant management systems

11. CGAP Decision Making/Risk Management TREE

12. Operational Risk Management Elements

13. HAZARD Definition • Condition, or circumstance which can lead or contribute to an unplanned or undesired event such as a mishap. • Examples: thunderstorms; wet or icy runways; obstacles in approach or departure path; FOD

14. Operational Risk Management Elements

15. Analyze Hazard: P-A-V-E • PILOT: certificate level, competency in aircraft, currency, experience • AIRCRAFT: performance, equipment, airworthiness, condition • ENVIRONMENT: weather, airport condition • EXTERNAL PRESSURE: purpose of flight, job, family, commitments

16. Operational Risk Management Elements

17. Risk Vs Benefits Analysis • LEVEL OF RISK: interms of hazard severity and probability of occurrence - Severity: catastrophic, critical, marginal, negligible - Probability: frequent, probable, possible, remote, improbable • ACCEPTANCE OF RISK:accept no unnecessary risk • WEIGHT/AMOUNT OF BENFITS VS RISK: accept risk only when benefits outweigh risks Example:Flight Instructor turns off fuel selector/fuel shutoff in flight in a single engine airplane to simulate loss of engine power

18. Risk Vs Benefits Analysis • WHAT IS THE HAZARD? • WHAT IS LEVEL OF RISK IN TERMS OF SEVERITY AND PROBABILITY OF HAZARD? - Severity: catastrophic, critical, marginal, negligible - Probability: frequent, probable, possible, remote, improbable • IS THERE UNNECESSARY RISK? • WHAT IS BENEFIT? • DOES THE BENEFIT OUTWEIGH THE RISK?

19. Operational Risk Management Elements

20. Develop Action Plan: T-E-A-M • Transfer: can the risk be transferred or shared? • Eliminate: can the risk be eliminated? • Accept: can the risk be accepted? (See Risk Vs. Benefits Analysis) • Mitigate: can the risk be mitigated? (Reduced to an acceptable level) Example:Planned IFR flight- lowest MEA's along route will be in IMC with forecast temperatures aloft at or below freezing

21. Develop Action Plan: T-E-A-M • WHAT IS THE RISK? • CAN THE RISK BE TRANSFERRED OR SHARED? • CAN THE RISK BE ELIMINATED? • CAN THE RISK BE ACCEPTED? • CAN THE RISK BE MITIGATED?

22. Operational Risk Management Elements

23. EXECUTE- Task Management (TM) Task Management is an integral part of the EXECUTE phase of ORM. Task: function performed by human as opposed to machine or system Task Management (TM): process by which pilots manage concurrent tasks required to safely and efficiently operate a modern aircraft. TM entails: - initiation of new tasks - monitoring on-going tasks - prioritization of tasks - allocation of resources based on priority - resumption of interrupted tasks - completion or elimination of tasks Critical Phases of Flight for TM: - pre flight preparation & planning - before take off/departure preparation - take off & initial departure - descent/approach preparation - initial approach/pattern entry phase - go around/missed approach

24. EXECUTE- Task Management (TM) Task Management affected by: - weather - stress - Air Traffic Control - aircraft condition - information/data overload Task Saturation: inability to perform task management due to one or more of factors above PRIORITZATION OF TASKS IS KEY TO AVOIDING TASK SATURATION!AVIATENAVIGATECOMMUNICATE

25. POST FLIGHT: "Lessons Learned" • Successful Operational Risk Management does not end when the flight is over! • After each flight the pilot should conduct a "lessons learned" review of the following: - What did I do well/right? - What did I do poorly/wrong? - Did I identify any hazards? - Were the hazards analyzed and the risks assessed? - Did I develop an action plan based on the risk assessment? - Did I execute my action plan? Was that plan successful? - Were there any occurrences which should be reported via an Air Safety or Hazard Report?

26. REMEMBER FOUR BASIC PRINCIPLES OF ORM • ACCEPT NO UNNECESSARY RISK • MAKE RISK DECISIONS AT APPROPRIATE LEVEL • ACCEPT RISK ONLY WHEN BENEFITS OUTWEIGH POTENTIAL OUTCOME • INTEGRATE ORM INTO ALL PHASES OF FLIGHT

27. REFERENCES - Aviation Instructor Handbook (FAA-H-8083-9A) - FAA System Safety Handbook - CGAP Safety Management System Manual - CGAP EA-500 Training Manual - Industry Standard Practices for Risk Management - Industry Standard Practices for Operating Excellence (Six Sigma)

28. FLY SAFELY!