Risk Management Handbook (FAA-H-8083-2A)
Mitigating Environmental Risks
Flight in the proximity of some environmental hazards may lead to serious or catastrophic accidents. Avoidance strategies
reduce the risk by lowering the accident likelihood. This requires pilots to plan, exercise patience, remain flexible, and be
creative.
Circumnavigate the Hazard
For some hazards, such as convective activity and very high terrain, a possible mitigation may be a plan to circumnavigate the
hazard.
Go Above or Below the Hazard
Sometimes a plan to fly at a different altitude reduces accident likelihood. Pilots can plan for altitudes that keep the aircraft
above or below icing conditions. Many instrument pilots who operate aircraft that are not approved for flight in known icing
conditions apply personal minimums to avoid conditions below certain temperatures or where the freezing level is at or below
the minimum en-route altitude.
Change Departure Time or Date
Advancing or delaying a departure may reduce risk likelihood. For example, on a day when a line of afternoon thunderstorms
is forecast, a pilot could plan for an early morning departure or wait until the thunderstorms dissipate and depart late in the
afternoon. For some meteorological hazards, such as an incoming low-pressure system, the pilot might choose to depart the day
before originally planned.
Cancel the Flight
Canceling a flight is necessary if the pilot cannot mitigate risk sufficiently by other means. The cancellation option is easier if
another means of transportation is available or if long-term rescheduling is an option.
Mitigating External Pressure Risks
External pressures can be either subtle or overt. Because it may involve passengers or others waiting for the arrival, it is best to
inform them of the need for flexibility.
Local Versus Transportation Flights
A local pleasure flight can still be subject to external pressures, but it is easier to cancel than a scheduled flight related to
transportation to an event. When planning a local flight with friends, for example, the pilot can reduce external pressures
by telling them in advance that the flight could be canceled at the last minute due to weather or other reasons. For an IFR
transportation flight, persons meeting the flight can use an application to know if the flight will arrive as planned. For a VFR
flight anyone meeting the flight may wait at home and get notified after the flight arrives.
Personal Versus Business Flights
Pilots who fly business associates may feel significant external pressures. The pilot should manage passenger expectations and
may plan for alternative travel options as a means to reduce risk.
Case Study
Note: Refer to the case study supporting data in Chapter 3, Identifying Hazards and Associated Risks, and the risk assessment
matrix in Chapter 4, Assessing Risk, to continue the risk mitigation phase of the case study.
Risk Mitigation Analysis
Tricia diligently identified the hazards and assessed the risks of her proposed flight from Durango, CO to Santa Rosa, CA. She
should now mitigate the high and serious risks that she identified during the assessment phase. She identified four high and five
serious risks that she should attempt to mitigate by reducing risk likelihood, severity, or both.
Tricia starts by reconsidering the overall plan for this flight. She rules out making a non-stop flight because carrying the Smiths
and their baggage would require a reduced fuel load, which in this case is a serious (yellow) risk. In addition, the direct route
could lead to encounters with thunderstorms, icing conditions, areas of low ceilings, and high terrain. Furthermore, she realizes
they should leave Monday morning, rather than Tuesday, because of the incoming front and low-pressure area. She also notes
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that there may be an issue with fog and low ceilings at Santa Rosa due to the coastal marine layer. This may dissipate by noon,
but it is not yet possible to predict.
Tricia starts by calculating the allowable fuel load. With an empty weight of 1,903 pounds and a maximum allowable gross
weight of 2,740 pounds, the useful load works out to 837 pounds. Tricia weighs 130 pounds, the Smiths together weigh 340
pounds. Together Tricia and the Smiths have 120 pounds of baggage. Tricia also has an electronic flight bag (EFB) and pilot
gear totaling seven pounds. This leaves 240 pounds for fuel, which is 40 gallons. The airplane currently has 25 gallons on board.
There is a serious (yellow) hazard if making a gross weight takeoff from the Animas Air Park (00C). She decides to ask the
Smiths to take a taxi to the Durango – La Plata County Airport (KDRO), which is about a ten-mile ride for them and a 7-nautical
mile flight for her. It has a 9,200-foot runway. She can add 18 gallons of fuel before the short flight to Durango – La Plata County
Airport, and can depart from there at gross weight, which includes 40 gallons of fuel. She plans to make one additional fuel stop.
After a thorough analysis and weather briefing, she elects to fly a southern route to avoid hazardous weather. She plans to refuel
at the Barstow-Daggett, CA airport (KDAG). The 490 NM route from Durango – La Plata County Airport uses the Winslow,
AZ (INW) VOR as a waypoint and should take 3 hours and 15 minutes. She will have 4 hours and 30 minutes endurance. From
there, she will fly to Santa Rosa using the Palmdale, CA (PMD) VOR as a waypoint. This route is 390 NM and should take 2
hours 45 minutes with a 4 hour and 30 minute endurance. [Figure 5-1]
Figure 5-1. Modified route.
The total distance along this route is 880 NM, versus the straight-line distance of 711 NM. The additional 169 NM adds about
1 hour and 15 minutes to the total flight time.
She mitigated the aircraft and environmental risks using this plan. She should also deal with the external pressure risks associated
with leaving a day early, given the need for the Smiths to forgo the Monday festivities in Durango. An early departure also
reduces the external pressures associated with making the Tuesday afternoon meetings on time. Tricia needs to explain the risk
analysis to the Smiths and show them why a Monday departure is necessary.
She has concerns related to her instrument proficiency. To compensate, she decides to add 500 feet to her personal minimums
for an instrument approach into Santa Rosa. This might require landing at a suitable alternate airport. With the predicted fuel
load, she calculates that Sacramento Executive Airport (KSAC), 62 NM from KSTS and well inland, would be a good alternate.
She also considers pilot aeromedical risks. She will consume no alcohol, have an early dinner, and go to bed early. She also
increases her intake of water. These actions should help avoid dehydration.
Having addressed all the previously identified risks, she completes the FRAT for the proposed trip, listing all of her mitigations.
The completed FRAT in Figure 5-2 shows all the risks mitigated to medium or low levels. For illustrative purposes, the
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recalculated risk levels are shown on one sheet showing the before and after. When the conditions change significantly, such as
for rescheduling or a change of aircraft, the pilot would normally redo the risk analysis using a fresh worksheet.
Flight Risk Assessment Tool
PAVE Area Hazard Risk Likelihood Severity Composite Risk Mitigation Results
Pilot “P”
Aircraft “A”
Environment “V”
External Pressure “E”
Capability
Aeromedical
Not IFR proficient
Alcohol and lack of sleep
LOC
Fatigue related errors
remote
occasional
catastrophic
critical
Fuel/Range/Payload
Equipment
Cannot carry full fuel
Not certified for known ice
Fuel exhaustion
LOC
remote
occasional
catastrophic
catastrophic
Performance Marginal takeoff performance Overrun, LOC, or CFIT occasional critical
Personal & Business Meeting deadlines for myself and Ms. Smith Increased risk in all other categories probable catastrophic high
high
high
high
high
serious
serious
serious
serious
Weather
Terrain
Thunderstorms, icing, low ceilings
High terrain
LOC and CFIT
CFIT
occasional
occasional
catastrophic
catastrophic
Airspace, ATC, Airports High density altitude CFIT occasional catastrophic
Add 500' to minimums improbable/catastrophic now
medium
No alcohol/adequate rest remote/marginal now
medium
Avoid icing conditions remote/marginal now medium
Add fuel stop improbable/negligible now low
Brief Smiths, depart Monday AM, shuttle Smiths to
KDRO, Add fuel stop improbable/negligible now low
Depart from KDRO remote/marginal now medium
Deviate south improbable/critical now medium
Fly well south of front remote/critical now medium
Depart from KDRO remote/marginal now medium
Figure 5-2. Case study FRAT with risks mitigated.
Of the nine risks assessed, she originally assessed four as high (red) and five as serious (yellow). According to her analysis and
mitigations, the risk for the current plan has seven medium (green) and two low (white) risks.
Tricia meets with the Smiths. They agree with the early departure from Durango and the other mitigations. Matt Smith makes
a few phone calls and returns with word that all of Monday’s festivities will go forward, but without the Smiths in attendance.
This risk mitigations used for the flight include the following:
1. Adding a safety margin to personal minimums for instrument approaches;
2. Abstaining from alcohol consumption, eating properly, and getting sufficient sleep;
3. Reducing the departure fuel load and adding a fuel stop;
4. Rescheduling to depart a day early;
5. Departing with passengers from the Durango – La Plata County Airport, rather than from Animas Air Park; and
6. Flying along a more southerly route to avoid weather hazards.
While on the ground in Daggett, CA for the planned fuel stop, Tricia checks the weather, which shows that the fog and low
ceilings are persisting at Santa Rosa. She understands the potential consequences of slightly elevated risk if making an ILS
approach with a 200- to 300-foot ceiling, and confirms her risk analysis remains valid by noting that her alternate, Sacramento
Executive Airport, is reporting clear skies as forecast. She prepares her EFB for the possible diversion to Sacramento and reviews
the airport information. This preparation alleviates the stress she may feel about diverting. She relieves external pressures by
discussing a potential diversion with the Smiths, who indicate they will accept whatever decision she makes.
Within an hour after departure, the fog at Santa Rosa has lifted, and she executes a routine landing.
Several days later, Tricia receives a complementary note from the Smiths praising her consideration for safety.
Balanced Approach to Risk Management
The hypothetical case study used in Chapters 3 through 5 represents a moderately complex scenario covering the flight of a
general aviation aircraft on a transportation flight.
It is appropriate to conduct a full risk management process for any flight, including the use of a FRAT. However, for less
complex flights, such as a flight in the vicinity of the airport on a sunny day with no wind, the completion of a FRAT may not
be necessary.
To enhance risk management accuracy and skill, consider the following steps:
• Take risk management and SRM courses.
• Obtain risk management training from a flight or ground instructor.
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• Use a formal risk management process to reduce risk on all complex flights.
• If not using a FRAT, continue to use the PA VE checklist to identify hazards and assess and mitigate the associated
risks.
Chapter Summary
Risk mitigation identifies hazards and reduces the likelihood or potential severity of associated risks. It may allow a pilot to
undertake a flight that would otherwise generate unacceptable risk. In other cases, the risk mitigation process may identify high
and serious risks that cannot be mitigated, which may require rescheduling, cancellation, or alternate transportation. A FRAT
can enhance any risk mitigation analysis, but may not be required for simpler flights, provided the pilot has sufficient risk
management skill. A brief FAA Safety Team (FAASTeam) video on risk-based decision-making summarizes many concepts
discussed in this chapter.
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Introduction
Pilots use risk management as described in earlier chapters to analyze the likelihood and potential severity of an incident or
accident based on identified hazards. The process takes time, thought, and collection of information pertinent to the flight.
However, once a planned operation begins, a pilot may encounter unforeseen hazards or threats. In addition, a pilot may respond
inappropriately to a given condition, thus making an error. This chapter provides strategies pilots may use once flight begins.
Threats
Threats have the following characteristics:
• Threats occur outside the influence of the flight crew; they are not controlled by the pilot.
• Threats increase the operational complexity of a flight.
• Threats may appear suddenly, and may limit the time available for analysis.
• A threat requires effective management to contain risk within acceptable levels.
Some common threats include:
• Malfunction of aircraft systems, engines, flight controls, or automation.
• Various unforecast weather hazards.
• Collision hazards, including wildlife on airports and birds in the air.
• Unexpected sudden reductions in visibility.
• Closures of facilities, runways, or taxiways while en route.
• Unreported poor braking action or surface contamination.
• Malfunction of a radio navigation aid or service after takeoff.
• Unexpected ATC clearances, restrictions, or reroutes that may significantly increase workload.
• Controller errors, radio congestion, or communication failure.
• Cabin events.
• Undetected improper refueling or fuel contamination.
What is an Error?
Errors are deviations from intended or expected actions and result in a reduction in safety margins. They include both
unintentional and intentional acts. They do not require the presence of a threat and can occur spontaneously. Errors may cause
confusion and increase workload.
Causes of Errors
Errors may result from insufficient training and experience, inadequate flight planning or preparation, external pressures, and
physiological and psychological effects.
Insufficient Training & Experience
A pilot who lacks training or experience regarding a given set of conditions may not be in a position to respond appropriately to a
related sequence of events and the potential for an inappropriate decision or error increases. Organizations often provide training
and supervised operating experience for this reason. General aviation pilots who are enthusiastic about meeting new challenges
Chapter 6: Threat and Error Management
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may find themselves in an unfamiliar situation that may result in serious errors. Pilots seeking the thrill of an adventure should
consider the potential danger from errors that may occur.
Inadequate Flight Planning or Preparation
Chapters 3, 4, and 5 of this handbook discuss risk analysis as an important step in the flight planning process. However, the
pilot can only conduct a preflight risk analysis based on the information gathered before flight. Inadequate flight planning may
leave a pilot in unanticipated conditions and can lead to errors. For example, a pilot dropped off a passenger at the Edward F.
Knapp State airport (KMPV) in rural Vermont and expected to refuel for the return trip to White Plains, New York (KHPN).
Upon arrival, fuel or other services were not available since it was the weekend. The pilot thought about waiting but decided
to fly home after estimating the fuel would be sufficient. The pilot filed a flight plan in the air as visibility started to diminish
after departure. Soon after, ATC required a hold as the destination airport had closed for snow removal. The entire region
was becoming affected by a snowstorm, and the pilot was running low on fuel. Luckily, after explaining the situation to the
controller, the pilot was able to divert to Bridgeport in Connecticut (KBDR), which was the last airport open in the area.
Fortunately, the ceiling was just above minimums for the instrument approach, and the pilot was able to land the aircraft in a
few inches of snow. Bridgeport closed shortly thereafter for snow removal.
Physiological Effects
Some of the items listed on the I’m Safe checklist (illness, medication, stress, alcohol, fatigue) have the potential to cause pilot
errors. For example, it may become difficult or impossible for a stressed or fatigued pilot to focus on a situation or task. Not
acting when necessary also constitutes an error.
Limitations affect human senses and perception. For example, when will a pilot see another aircraft on a collision course?
The avoidance maneuver may depend not only on where the pilot is looking, but also on the pilot’s individual sense of vision
combined with all the visual signals received at the same time.
Psychological Effects
Psychological effects include stress, emotion, expectation bias, and the effects of personality.
Stress & Emotion
While pilots should self-evaluate for stress and emotion during preflight mitigation analysis, stress and emotion do sometimes
affect a flight in progress. External pressures from outside sources including supervisors, family, and friends may bias a pilot to
make an error in an effort to complete a flight as originally planned. What does the pilot actually think about before making a
decision? Does the desire to complete a flight as planned influence or outweigh the need to reduce risk? Only the pilot knows
the thought process that leads to a decision, but making safety other than the top priority may cause the pilot to err.
An emotional response could appear spontaneously and lead to an error at any time. After an emotional shock or an important
life event, the pilot may not be able to concentrate on the current conditions. On the other hand, individuals may become
relaxed during flight and may not be sufficiently alert to react to a threat or error. Occasionally, pilots overfly their destination
because they have become completely relaxed. If here today, Aristotle would say that errors become more likely if the pilot is
obsessed to the point of exclusion of all else or if the pilot is generally disinterested in the events at hand. Appropriate focus
and concentration are the golden mean.
Expectation Bias
A pilot's erroneous assessment may persist even though it is wrong and despite available evidence to indicate the error. The
term for this phenomenon is expectation bias. The NTSB has investigated numerous accidents and incidents that involved pilot
errors resulting from expectation bias, particularly in night VMC when fewer cues aid in airport and runway identification.
For example, in January 2014, a Boeing 737 landed at the wrong airport in Branson, Missouri, in night VMC. The flight crew
expected that the visually identified airport and runway were the intended destination and did not reference flight deck displays
to verify the airport and runway. As a result, the airplane landed on Runway 12 at M. Graham Clark Downtown Airport instead
of Runway 14 at Branson Airport.
A general aviation pilot routinely flew to a specific airport with parallel runways. The airport had one runway closed by
NOTAM for several months, but after some time, the runway closure was reversed. The NOTAM was no longer for 19R/1L, but
for 19L/1R. Even after reading the NOTAM and listening to the ATIS broadcast, the pilot perceived it as it had been previously.
An error occurred when the pilot initiated an approach to the closed runway.
When presented with conflicting information, some pilots will try to suppress that information if it does not fit in with the
expectation rather than triggering an internal “uh-oh.” The phenomenon, not to be confused with expectation bias, has the
slightly different name “confirmation bias.” The result of either, if uncorrected, may lead to an error. Either case results in the
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pilot continuing with a plan despite clues indicating the situation is not as perceived. Fatigue tends to stop pilots from taking
extra steps to verify perceived reality and contributes to expectation and confirmation bias susceptibility.
An incident at the San Francisco, California airport (KSFO) is another example involving expectation bias. The NTSB docket
for this incident provides extensive information regarding expectation bias and is available here.
Expectation bias often occurs on the ground while taxiing. Pilots may expect a particular taxi route and perceive the clearance
as expected rather than as given by ATC. Pilots familiar with a particular airport who routinely receive the same taxi clearance
may be more susceptible to this error.
Pilots are often thought of as being calm and rational. Like all people, each pilot has a different personality. A normal ability to
face reality, handle anxiety, and think rationally under pressure varies over a range. How a particular pilot reacts to a threat may
depend on training and experience and may vary considerably. When a threat appears and calls for a decision, two hazardous
attitudes may come into play. A pilot might react impulsively without due consideration or with resignation and not respond in
a timely manner. Either extreme may increase workload and confusion and may not address a threat or error properly.
What is an Undesired Aircraft State?
Flight crew error creates an undesired aircraft state described as:
• Incorrect aircraft position, speed, attitude, or configuration.
• An in-flight situation that causes pilot confusion and increased workload.
• Reduced safety margins and increased risk from threats or errors.
Defenses against Threats, Errors, and Undesired Aircraft States
When a pilot perceives a flight condition that requires attention, the pilot may know what to do immediately or may need time
to process alternatives. The pilot may utilize several different strategies and defenses to manage risk while in the air.
Defenses Provided to the Pilot or Crew
A manufacturer, employer, or a flight school may provide defenses to pilots. Examples include checklists, operating limitations,
minimum pilot qualifications, standard operating procedures, and insurance requirements. Regardless of the flight mission,
some defenses will always be predetermined.
Checklists, Standard Operating Procedures, and Best Practices
Like the aircraft, its approved checklists are normally provided. The manufacturer’s approved checklists, placards, and emergency
procedures provide a basic defense against threats, errors, or undesired aircraft states. Many flight schools, flying clubs, and
larger flight departments may develop checklists and standard operating procedures (SOPs) that enhance the procedures
provided by the manufacturer. Many aircraft owners participate in type-specific owner organizations that develop and share
best practices. A short video on developing a checklist that includes optional or aftermarket equipment is available here.
Utilizing a Second Pilot or Person
Even when flying a single-pilot aircraft, a pilot may choose to fly with a second pilot. The second pilot may be a flight instructor
or another pilot who can perform some flight duties. The pilot can also assign specific duties to a passenger who can help
monitor certain conditions or read a checklist. Pilots should consider how to use an additional person appropriately since a
resource could also introduce threats.
External Resources
Flight service personnel are a valuable resource, especially for weather avoidance and flight plan changes. Air traffic control
can assist pilots with traffic avoidance, weather avoidance, terrain avoidance, and navigation. However, ATC workload or