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Reliance on Automation
12279
The use of automation comes with certain cautions. Automation should reduce workload, but in some instances, it may create
more work, confusion, and contribute to errors. At other times, automation may lull pilots into complacency. Pilots who
consistently rely on an autopilot for flight path management may experience degraded ability to fly manually when required
to do so. For example, when flying in icing conditions, an automated system may make control inputs to compensate for ice
accumulation. However, if the system exceeds its limits, it could disconnect and leave the aircraft in an undesired state. A pilot
who has become unaccustomed to manual flight may not be prepared to handle the situation.
12290
Reprogramming tasks that occur unexpectedly can trigger pilot errors, which may result in flight path deviations or other
undesired aircraft states. Pilots should anticipate the need to fly manually and be prepared to maintain the desired flight path
when manual control becomes necessary.
12287
Pilots who use automation should train and practice for various scenarios in order to avoid becoming overly distracted when
making a programming change or correcting an error. Being startled or confused by a programming mistake or automation
malfunction occurs less often when the pilot has the capability for transition to manual flight. If the automation is not functioning
according to expectation, the pilot may reduce the level of automation, fly manually, and take time to resolve the condition.
Balancing Automated & Manual Flight
12291
Pilots choose the level of flight path automation. Risk management strategies suggest using automation as an aid to manage
workload rather than to compensate for lack of proficiency. A balance of automated and manual flight that takes workload and
proficiency into consideration gives the pilot greater opportunity to monitor the flight path and aircraft state.
12291-2
Choosing the appropriate level of automation for the task and adjusting as circumstances dictate is essential to effective use of
automation. One of the most common errors is failing to move to lower levels of automation suitable to a changing environment.
12292
For example, a pilot may track an approach course adequately using manual control inputs. However, the pilot may also need to
listen to and record the Automatic Terminal Information Service (ATIS), retrieve and load an instrument approach procedure,
prepare for the instrument approach, and accomplish the appropriate checklists. These tasks will increase workload and divert
pilot attention from monitoring and controlling the flight path. If using an autopilot to track the approach, the automation
performs the control inputs and allows the pilot to complete other tasks quickly and efficiently.
12293
Continuing the scenario above, the pilot loads the instrument approach and decides to remain on autopilot. However, after the
aircraft passes the initial approach fix, ATC cancels the approach clearance. ATC provides vectors and tells the pilot to expect
to hold. In this situation, the pilot may select basic autopilot modes that control heading and altitude in order to comply with the
assignment from ATC. The lower level of automation allows the pilot to program and configure the aircraft for an unexpected
change while keeping the flightpath and aircraft state under control.
12295
Pilots may sometimes choose to disengage the automation and fly the aircraft manually to maintain proficiency.
Interacting with Automation
12296
Regardless of the level of automation, pilots should consider the following series of steps: [Figure 7-2]
12297
1. Anticipate – Understand the system well enough to know what should happen before pushing a button or turning a
knob.
12298
2. Act – Execute button pushes and knob turns to implement the desired automation.
12299
3. Verify – Ensure the aircraft or avionics performs as expected.
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Risk Management Handbook (FAA-H-8083-2A)
12300
Figure 7-2. Steps for interacting with automation
12301
Understanding autopilot function and logic allows the pilot to anticipate, act, and verify the autopilot performs as expected.
Figure 7-3 shows a typical flight mode annunciator displayed on the primary flight display (PFD) of a general aviation integrated
flight deck. A pilot without adequate training may not anticipate that a change or disruption of the navigation source may reduce
the level of automation, and horizontal flight path control may default to wings level mode. If this should occur unexpectedly,
it could lead to increased workload, confusion, or result in an undesired aircraft state.
12302
LOC HDG AP ALT 9000FT GS
Figure 7-3. Flight mode annunciators in green indicate the autopilot is engaged in heading “HDG” and altitude “ALT”
mode, maintaining 9,000 feet MSL. The white “LOC” and “GS” annunciators indicate approach mode is armed but not
engaged.
Failure to Anticipate, Act, & Verify
12304
Automation offers increased safety with enhanced situational awareness. However, these systems make it possible for a pilot to
become complacent, unprepared, or lose situational awareness. If this occurs and an unexpected change in flight plan is needed,
workload and confusion may suddenly increase.
12306
In a 1995 fatal accident in Colombia, a flight crew was unexpectedly cleared for an approach, lost situational awareness, and
crashed into mountainous terrain. The accident summary cites failure of the flight crew to revert to basic radio navigation at the
time when the FMS-assisted navigation became confusing and created an excessive workload in a critical phase of the flight.
The system flew on a programmed path into a mountain, resulting in many fatalities. A narrative of the accident is available here.
12307
As part of a lack of situational awareness, the workload and confusion resulted in the crew failing to retract the aircraft speed
brakes when they became aware of the terrain ahead and after adding full thrust. This prevented the aircraft from climbing above
the slope of the mountain ahead.
Integrated Flight Path Automation Systems
12310
Use of automation is an excellent risk control measure when flying in a variety of flight environments where the pilot has a high
workload. For example, autopilots are often very useful during complex single-pilot operations. While the use of automation
helps reduce risks associated with other hazards, a lack of proficiency with automation may become its own hazard and introduce
unique risks. While pilots often rely on the autopilot, they also need to be able to fly the aircraft manually within appropriate
standards.
12308
Pilots should train and practice using automation under VFR with an appropriately qualified and knowledgeable flight instructor
before attempting IFR flight. In addition, using a flight simulation training device provides the opportunity to practice and
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Risk Management Handbook (FAA-H-8083-2A)
repeat automation procedures with a simulated high workload. Through appropriate training and practice, pilots learn to operate
autopilot systems with ease and in a routine manner.
12309
Knowledge of system limitations and operating restrictions is also important. Pilots should know emergency procedures pertaining
to disconnecting the autopilot as well as being able to locate appropriate checklists. Reviewing the system documentation and
aircraft flight manual supplements helps develop this knowledge.
Chapter Summary
12313
The increased use of automated systems, autopilots, and integrated flight decks help pilots manage an aircraft’s flight path.
While an autopilot is engaged, a pilot’s attention should not disengage. Pilots need to maintain situational awareness and
appropriate focus on the progress of the flight at all times. Balancing the use of automation with manual flying skills is necessary
in case a particular situation requires pilot intervention. Using automation proficiently and at the appropriate level reduces risk
and helps prevent incidents and accidents.
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Risk Management Handbook (FAA-H-8083-2A)
Introduction
12317
This chapter focuses on the pilot aeronautical decision-making (ADM) skills used to mitigate risk factors while in flight.
Advisory Circular (AC) 60-22, Aeronautical Decision-Making [ Figure 8-1 ], provides additional information, background
references, definitions, and other pertinent information about ADM training in the general aviation environment and is available
here.
12318
Figure 8-1. Advisory Circular (AC) 60-22, Aeronautical Decision-Making, includes a wealth of information for pilots.
12316
Accidents still occur despite advances in training methods, aircraft technology, and services available to pilots. Despite
improvements in training and technology, human error remains an issue. ADM provides a foundation, which should help pilots
avoid making errors in judgment.
12314
Aeronautical decision-making (ADM) provides pilots with a structured framework of processes and procedures, which have a
positive effect on managing hazards. ADM does not eliminate hazards, but helps the pilot address hazards and associated risks
that threaten the safety of flight. ADM describes the ongoing process used by pilots to determine the best course of action when
facing a given set of circumstances.
ADM Background
12319
Before the development of ADM training, consensus held that good judgment resulted from experience gained during hours
of accident-free flying. However, research done during the 1980s indicated that including ADM in training significantly
reduced judgment errors among student pilots. In addition, an operator flying about 400,000 hours annually demonstrated a 54
percent reduction in the accident rate after adding ADM to recurrent training. Since ADM enhances safety, the Federal Aviation
Administration (FAA) requires ADM training and testing.
Analytical Decision-Making
11880
Several closed-loop models describe steps pilots should take when making decisions. For example, AC 60-22 contains
information on the DECIDE Model, which pilots may wish to study and consider using. The following discussion describes
the simpler 3P model, which stands for Perceive, Process, and Perform. [Figure 8-2] Using this model in flight continues the
Chapter 8: Aeronautical Decision-Making in
Flight
8-1
Risk Management Handbook (FAA-H-8083-2A)
risk management activity taken before flight, and allows the pilot to address additional hazards while dealing with a higher
workload.
12348
Aeronautical
Decision-
Making
(Perceive)
(Perform) (Process)
Figure 8-2. The illustration shows how the 3P model is used in decision-making.
12331
Perceive: While en route, for example, a pilot checks data-link weather on an electronic flight bag and sees thunderstorms
developing ahead. The pilot perceives this as a significant hazard since the likelihood of a thunderstorm affecting the aircraft
could be high and the consequences could be severe.
12332
Process: The pilot considers the options available to mitigate the threat. Choices may include:
20701
• Diverting to a nearby airport
20702
• Turning back, if conditions allow
20703
• Rerouting the flight to avoid the thunderstorms
21925
• Flying above the weather.
12334
During analytical decision-making, the pilot evaluates the pros and cons associated with each option and chooses one that
should adequately reduce the level of risk. For example, the aircraft may not have the equipment or capability to fly above the
weather or there might not be enough fuel on board for a significant reroute. In that case, the pilot excludes those two options.
What the pilot decides depends on the available choices, training, experience, conditions, equipment, and pilot ability.
20704
Analytical decision-making leads to an option likely to result in a safe outcome. Pilots should consider the following items less
important than safety:
12335
1. Being on time
12336
2. Inconveniencing passengers
12337
3. Inconveniencing persons waiting at the destination
12338
4. Continuing to the original destination
12333
Perform: After choosing a viable option, the pilot executes the changes. The choice made should lead to a safe outcome.
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Risk Management Handbook (FAA-H-8083-2A)
12340
Effective risk management models utilize a closed-loop process. The closed-loop nature of the 3P model requires a periodic
check to verify successful mitigation of the risk. If the pilot perceives insufficient mitigation of that risk or detects a new hazard,
the process and analysis resumes.
Naturalistic Decision-Making
12346
Experienced pilots use naturalistic decision-making when the time available precludes a more formal analytical process. In this
type of scenario, pilots first assess whether the given situation strikes them as familiar. Rather than analyze the pros and cons
of different actions, a pilot might start with a course of action that seems workable based on previously encountered patterns.
12343
In this type of decision-making, pilots may recall previous events and choose a course of action based on expectations. In the
following scenario, a pilot’s familiarity with a previous incident led to a successful naturalistic decision.
12342
A turkey vulture impacted the front fan of a jet engine shortly after takeoff and destroyed the engine. Several titanium fan blades
departed the aircraft and the cabin filled with smoke. The crew landed safely after donning masks and goggles. The impact was
forceful enough to leave an impression of the feathers on some of the remaining blades. [Figure 8-3]
12344
Figure 8-3. Sheared off titanium fan blade with feather impressions.
12345
Years later, a pilot who investigated this bird strike was flying a turbojet. When a large bird appeared in the departure path, the
pilot delayed rotation a few seconds, and the airplane flew under the bird without incident. Visualizing what could happen,
knowing that there were no obstacles ahead, sensing that a short delay would not exceed any limitations, and remembering that
instructors mentioned that pilots might delay rotation if conditions warrant, the pilot made a split-second decision to extend the
takeoff roll beyond rotation speed.
20841
In summary, naturalistic decision-making improves with training and experience, and it is not a replacement for memory items
or a checklist procedure. Pilots typically use naturalistic decision-making when a situation requires immediate action and is not
covered by an existing procedure.
Single-Pilot Resource Management
12349
Single-pilot resource management (SRM) specifically refers to appropriate management of all resources available to the single
pilot. SRM includes competencies such as situational awareness, communication skills, teamwork, task allocation, aeronautical
decision-making, risk management, controlled flight into terrain (CFIT) awareness, and automation management. Resources
are found both inside and outside the aircraft. Many of the concepts are similar to crew resource management (CRM).
12350
Learning to recognize these resources is an essential part of SRM. In addition, a pilot should evaluate whether there is time to
use a particular resource. For example, ATC assistance may be very useful if a pilot becomes lost, but there may be no time to
contact ATC in an emergency. During an emergency, a pilot needs to prioritize tasks and manage workload.
20874
Many older aircraft may have modern equipment installed, which require a flight manual supplement. This equipment can be a
valuable single-pilot resource if the pilot uses the equipment proficiently and adjusts procedures appropriately. In some cases,
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Risk Management Handbook (FAA-H-8083-2A)
the procedures for new equipment affect the aircraft checklists. A short video on modern installations and checklist management
is available here.
12351
In a single-pilot operation, pilots often gather, organize, and manage available resources before flight to make it easier to
assess and manage risks and make informed aeronautical decisions. The comprehensive planning and preparation activities
described earlier in chapters 3, 4, and 5 facilitate SRM. If the pilot prepares for scenarios that may occur during a flight, such
as a diversion or precautionary landing, it becomes easier to consider and perform that option with the needed information
at hand. For example, while en route to an airport the aircraft alternator fails. After completing the appropriate checklist, the
alternator remains off line, and the battery will only provide electricity for a short time. The pilot decides to divert to the nearest
suitable airport. Does the pilot know the destinations along the route of flight that qualify? Did the pilot organize personal and
flight deck resources to access information such as communication frequencies and navigation aids for the available airports?
By considering and organizing information before flight, the single pilot may perform such tasks with crew-like efficiency.
Chapter Summary
20844
Aeronautical decision-making occurs during all aspects of flight and begins during flight planning. When in flight, however,
pilots learn to deal with any threat using appropriate analytical thinking. The analytical process prevails unless time pressure
and lack of an existing procedure calls for naturalistic decision-making. The 3P model illustrates a closed-loop process that
pilots use to reinforce appropriate decision-making. Several models address ADM, and pilots should study and use the model
they find effective.
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Risk Management Handbook (FAA-H-8083-2A)
Scope
12420
Appendices A through D are designed to supplement the material in this handbook. To take full advantage of the appendices,
readers should become familiar with the material in Chapters 2, 3, 4, and 5.
12421
The information in these appendices is designed to cover single-pilot operation of general aviation aircraft. While multi-crew
operations may utilize concepts and programs such as crew resource management (CRM), safety management systems (SMS),
and advanced qualification programs (AQP), these programs also use risk mitigation principles discussed in this handbook.
How to Use
12422
Each appendix accomplishes a specific purpose.
12423
Appendix A, Risk Management Training, suggests integration of risk management into initial, recurrent, and specialized flight
training. Pilots should work with flight instructors to ensure risk management is included in initial training, training for additional
ratings, and currency events as appropriate. For example, a pilot in need of a flight review or instrument proficiency check
(IPC) may request a risk-based review or check. Instructors should refer to Chapter 10 of the Aviation Instructor’s Handbook
(FAA-H-8083-9, latest edition) to review teaching risk management.
12424
Appendix B, Risk Management Tools, lists assessment tools discussed in Chapters 3, 4, and 5. These include both numerical
and non-numerical flight risk assessment tools, models, checklists, and risk assessment matrix discussed in the chapters. This
section can be used as a reference while reviewing the cases and examples in Appendices C and D.
12425
Appendix C, Risk Management Accident Case Studies, reviews several fatal accidents from a risk management perspective.
Appendix C includes an analysis of four accidents, which include recreational flying, single-pilot operation of turbine-powered
airplanes, and a helicopter operation.
12426
Appendix D, Risk Management Exercises, contains four hypothetical scenarios. Questions are posed asking the reader to
conduct a risk analysis for each scenario. A solution is not provided as was done in Appendix C, and the reader may develop a
risk analysis for each scenario as an exercise.
Using Appendices as a Workbook
12427
The appendices provide an opportunity to apply the concepts covered in this handbook. These appendices bridge the knowledge
in this handbook, further risk management training, and the type of preparation that should occur before flight. For maximum
benefit, pilots should consider taking a risk management course.
Appendix Introduction
AI-1
Risk Management Handbook (FAA-H-8083-2A)
Integrating Risk Management Training and Other Training Requirements
12428
Application of risk management principles becomes more effective after specific training for this purpose. Sources of risk
management training include flight or ground instructors, schools, and commercial sources.
12429
The effectiveness of risk management training increases when integrated with the knowledge, risk, and skill requirements
contained in the applicable Airman Certification Standards (ACS).
12433
Risk management training will also be more effective if it is integrated with other SRM skills such as automation management,
task and workload management, and situational awareness. These higher order thinking skills are crucial to operating safely in
today’s aviation environment.
12435
Flight reviews, instrument proficiency checks, and other evaluation activities include the certification requirements for risk
management. These events should use scenarios designed to address the hazards and associated risks relevant to the pilot.
For example, external pressures could be simulated using a “what if” scenario that might arise for a pilot who regularly flies
associates or family to events that cannot be rescheduled.
Appendix A: Risk Management Training
A-1
Risk Management Handbook (FAA-H-8083-2A)
Risk Assessment Tools Identifying, Assessing, & Mitigating Risk
12461
This appendix contains tools readers may use to review the accident and case study examples in Appendices C and D from an
academic risk management perspective. For example, Figure B-1 depicts the PA VE checklist. Many of the tools described in
this appendix work to the same end, and pilots may use a combination of tools to manage risk. Instructors normally provide
training and guidance on the appropriate use of these tools.
12460
A pilot must continually make decisions about competency,
condition of health, mental and emotional state, level of
fatigue, and many other variables. For example, a pilot may
be called early in the morning to make a long flight. If a pilot
has had only a few hours of sleep and is concerned that the
sinus congestion being experienced could be the onset of a
cold, it would be prudent to consider if the flight could be
accomplished safely.
A pilot had only 4 hours of sleep the night before
being asked by the boss to fly to a meeting in a city
750 miles away. The reported weather was marginal
and not expected to improve. After assessing fitness
as a pilot, it was decided that it would not be wise to
make the flight. The boss was initially unhappy, but
was later convinced by the pilot that the risks
involved were unacceptable.
Pilot
The environment encompasses many elements that are not
pilot or airplane related, including such factors as weather,
air traffic control (ATC), navigational aids (NAVAIDS), terrain,
takeoff and landing areas, and surrounding obstacles. Weather
is one element that can change drastically over time and
distance.
A pilot was landing a small airplane
just after a heavy jet had departed
a parallel runway. The pilot
assumed that wake turbulence
would not be a problem since
landings had been performed under
similar circumstances. Due to a
combination of prevailing winds
and wake turbulence from the
heavy jet drifting across the landing
runway, the airplane made a hard
landing. The pilot made an error
when assessing the flight
environment.
Environment
A pilot frequently bases decisions on evaluation of the
airplane, such as performance, equipment, or airworthiness.
During a preflight, a pilot noticed a small amount of oil dripping
from the bottom of the cowling. Although the quantity of oil
seemed insignificant at the time, the pilot decided to delay the
takeoff and have a mechanic check the source of the oil.
The pilot’s good judgment was confirmed when the mechanic
found that one of the oil cooler hose fittings was loose.
Aircraft
The interaction between the pilot, airplane, and the
environment is greatly influenced by the purpose of each
flight operation. The pilot must evaluate the three previous
areas to decide on the desirability of undertaking or continuing
the flight as planned. It is worth asking why the flight is being
made, how critical it is to maintain the schedule, and if the
trip is worth the risks.
On a ferry flight to deliver an airplane from the factory, the pilot
calculated the groundspeed and determined he would arrive at
the destination with only 10 minutes of fuel remaining. A check
of the weather revealed he would be flying into marginal
weather conditions. By asking himself whether it was more
critical to maintain the schedule or to arrive with an intact
aircraft, the pilot decided to schedule a refuel stop even though
it would mean he would not be able to keep to the schedule.
He chose not to “stretch” the fuel supply in marginal weather
conditions which could have resulted in an emergency landing.
External Pressures
Figure B-1. The P AVE checklist.
Risk Identification Tools
12462
Pilots may also use the FRAT [Figure B-2], which incorporates the PA VE checklist to aid with hazard identification.
Appendix B: Risk Management Tools
B-1