Risk Management Handbook (FAA-H-8083-2A)
Figure B-5. 3P “Perceive” analysis and P AVE checklist risk identification.
Additional Risk Assessment Tools
The CARE checklist provides a breakdown of rationale pilots use during the 3P “ process” stage [ Figure B-6]. It includes a
perspective of what could happen (consequences), what may be done to prevent an unwanted outcome (alternatives), a check
of the actual conditions (reality), and an analysis of pilot motivation (external pressures).
Figure B-6. Process using the CARE checklist for risk assessment.
Risk Mitigation Tools
The TEAM checklist shares the “ perform” step in the 3P model as well as the “alternatives” component from the CARE
checklist.
Figure B-7. “Perform” using the TEAM checklist for risk mitigation.
Analysis of hazards and associated risks may follow the six-step DECIDE Model shown in Figure B-8.
Risk Management Handbook (FAA-H-8083-2A)
1.
2.
3.
5.
6.
The DECIDE Model
Figure B-8. The DECIDE Model.
Risk Management Handbook (FAA-H-8083-2A)
General Information
The fatal accident profiles described below represent a range of general aviation activities. For additional accident information
search the NTSB Aviation Accident Database here.
For each accident, a summary using the PA VE checklist highlights potential risk factors that, in retrospect, may teach something
about decision-making. The analysis includes an assessment of risks, as well as potential mitigations that could have altered
the outcome. Individuals may use a variety of other tools, models, and checklists including those outlined in Appendix B to
perform a similar analysis.
The accident case studies outlined below involve single-pilot operations. Analysis of accidents involving flight crew operations
could also include a discussion of crew interaction and resource management (CRM) principles.
Accident Profile 1: Fatal Accident in a Single-Engine Airplane with a Piston Engine
The following details pertain to this accident:
• Location: Veneta, OR (Crow-Mag airport, 33OR)
• Date: 06/23/2012
• NTSB Defining Event: Loss of lift
• NTSB Case File Number: WPR12FA274
NTSB Probable Cause
The pilot’s failure to maintain adequate airspeed and altitude to clear trees during the initial climb after takeoff.
NTSB Factual Summary Excerpts (edited)
The pilot was carrying three passengers on a local scenic flight, and the aircraft was near maximum gross weight. Visual
meteorological conditions prevailed at departure. The 3,100-foot turf runway had 3-inch or higher wet grass and there were
100-foot trees at the end of the runway. The pilot operating handbook (POH) showed approximately 1,700 feet required for a
takeoff from a hard-surface runway over a 50-foot obstacle. The POH did not provide takeoff data for a turf runway with wet
grass or a 100-foot obstacle.
After departure, the aircraft descended into the trees. A cell phone video taken from inside the aircraft recorded the sound of
the stall warning just before the collision. Witnesses reported seeing the aircraft descend into the trees. All four occupants
died during the crash. An autopsy toxicology report indicated the presence of marijuana in the pilot’s bloodstream; however,
the degree of pilot impairment could not be determined. The investigators could not find any aircraft defects that would have
prevented it from achieving full power on takeoff.
Risk Identification, Assessment, and Mitigation
The hazards associated with this accident may involve all four categories of the PA VE checklist. However, environmental and
aircraft performance hazards may have generated the highest risk levels.
The primary environment hazards in this accident are the 100-foot trees at the end of the runway and the wet-grass turf runway.
These environmental factors, coupled with an aircraft hazard arising from takeoff and climb performance limitations, generated
the risk that may explain the accident. An external pressure hazard associated with pleasing the passengers may have existed.
A pilot aeromedical hazard existed due to marijuana use. There is evidence taking illicit drugs significantly elevates the risk of
having an aviation accident. Even though the Drug Enforcement Administration (DEA) defines marijuana as a Schedule I drug
on its controlled substances list, states have taken steps to allow the possession, sale, and use of marijuana within their borders.
The FAA has stated, “Marijuana is an illicit drug per federal law, and its use by airmen is prohibited.”
The risk severity generated by the collision potential with the trees is “catastrophic” because it resulted in loss of life. Given
the environment and aircraft performance limitations that the pilot could have reasonably anticipated, the likelihood of the risk
Appendix C: Accident Case Studies
Risk Management Handbook (FAA-H-8083-2A)
was at least “occasional,” that is, it would probably occur sometime. Consulting the risk assessment matrix, the resulting risk
is high (red) and requires mitigation to a lower level of likelihood and/or severity.
Because the airplane was located at the turf airport, avoiding risk generated by the trees warranted careful consideration. The
pilot could have greatly reduced the likelihood of an accident by flying the aircraft solo to the nearby Eugene, OR (EUG) airport
to pick up the passengers [Figure C-1]. This single action addresses both the environmental and aircraft performance risks. This
could also have reduced the external pressures.
Figure C-1. Sectional chart excerpt.
Accident Profile 2: Fatal Accident, Turboprop-Powered, Transportation
The following details pertain to this accident:
• Location: Morristown, NJ
• Date: 12/20/2011
• NTSB Defining Event: Loss of control in-flight
• NTSB Case File Number: ERA12FA115
NTSB Probable Cause
The airplane’s encounter with severe icing conditions that were characterized by high ice accretion rates and the pilot’s failure
to use command authority to depart the icing conditions in an expeditious manner, which resulted in a loss of airplane control.
NTSB Factual Summary Excerpts (edited)
The pilot departed Teterboro, NJ (TEB) on an IFR flight plan to Atlanta, GA (PDK). No evidence of a weather briefing was
found, although the pilot may have obtained weather information from non-government sources. There was an AIRMET for
moderate icing in northern New Jersey and westward from the freezing level (2,000 to 8,000 feet) to 20,000 feet. There were
numerous pilot reports of moderate to severe icing and a Center Weather Advisory (CWA) issued, as depicted in Figure C-2.
Risk Management Handbook (FAA-H-8083-2A)
Figure C-2. CWA moderate to severe icing area.
The pilot reported entering light icing at 16,800 feet and requested a higher altitude. There was a delay before air traffic control
subsequently approved a climb to Flight Level 200. The radar track showed the airplane reached a peak altitude of 17,800 feet
before beginning a rapid descent. The aircraft disintegrated during the descent and all five occupants perished. The airplane's
flight manual included a warning that the aircraft was not approved for flight in severe icing conditions.
Risk Identification, Assessment, and Mitigation
No pilot risk factors were identified. The pilot was qualified in the aircraft and had recently attended recurrent training. As with
any transportation flight, there may have been external pressures to complete the flight as planned.
The severity of the combined risk is catastrophic because it resulted in the loss of five lives. Given the severity of the icing,
the length of exposure, and the warning in the airplane's flight manual, the likelihood of the event was at least “occasional,”
meaning it would probably occur sometime. Thus, the overall risk level was high and needed mitigation.
How could the pilot have mitigated the risk factors on this flight? One way may have been to file for 10,000 feet to stay under
the icing conditions. The pilot could maintain this altitude until exiting the severe icing area somewhere in southern New Jersey.
This would have decreased fuel efficiency, but it would not have taken much time to reach an area without icing. At that time,
the pilot could request a climb to a more fuel-efficient altitude. While the lower altitude may generate a requirement for a fuel
stop, that stop represents an inconvenience only.
Accident Profile 3: Fatal Accident, Helicopter, Personal Flight
The following details pertain to this accident:
• Location: Panacea, FL
• Date: 02/08/2014
• NTSB Defining Event: Collision during takeoff/land
• NTSB Case File Number: ERA14FA115
NTSB Probable Cause
The pilot’s failure to maintain adequate clearance from trees during a takeoff at night. Contributing to the accident was the
pilot’s lack of recent night flight experience.
NTSB Factual Summary Excerpts (edited)
The pilot and two passengers flew from the Tallahassee, FL airport (TLH) to the nearby Wakulla County Airport (2J0). The
purpose of the flight was to dine at the restaurant across the street. It was dusk when they arrived at 2J0.
Risk Management Handbook (FAA-H-8083-2A)
After dinner, they returned to the helicopter for the return flight. The Wakulla airport and the area around it were poorly lit, and
after liftoff, the helicopter impacted 50-foot trees about 350 feet from the liftoff point. The pilot and one passenger suffered fatal
injuries and the other passenger was severely injured.
The pilot had only one hour of night flight experience in the previous 11 months and did not possess an instrument rating.
Witnesses to the accident stated the area around the airport was dark or “very dark.” The pilot was taking a disqualifying drug
that can cause drowsiness, although the NTSB did not assert this as a factor in the accident.
The surviving passenger stated that the pilot was in a hurry to return home and spend time with his daughter.
Risk Identification, Assessment, and Mitigation
At least three of the four risk categories in the PA VE checklist may relate to this accident. The pilot had minimal night currency
for this flight. In addition, aeromedical factors may have affected the pilot’s perception of the environment.
The airport environment hazard contributed to the risk present at takeoff. The 50-foot trees near the takeoff zone resulted in a
normal takeoff and climb that did not provide safe clearance during climb out. A hovering takeoff and climb also might have
been hazardous at night in a dark environment.
External pressures relate to the pilot’s desire to return as soon as possible. Perhaps this caused him to rush through the start-up
and liftoff with reduced situational awareness of the airport environment.
The collective risk severity level for this accident was catastrophic. The risk likelihood was at least occasional, producing a high
overall risk level. Avoiding nighttime operations at this particular airport could have been a key mitigation.
Accident Profile 4: Fatal Turbojet-Powered Airplane Accident
The following details pertain to this accident:
• Location: Cleveland, OH
• Date: 12/29/2016
• NTSB Defining Event: Loss of control in-flight
• NTSB Case File Number: CEN17FA072
NTSB Probable Cause
Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion
related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences
from the pilot’s previous experience.
NTSB Factual Summary Excerpts (edited)
The pilot and five passengers flew to the Burke Lakefront Airport (BKL) earlier to attend a sporting event. They arrived back at
BKL around 2230 for the return flight to Columbus, Ohio. Although BKL was VFR, the ceiling was 2300 feet and the departure
took place in full darkness. Within two minutes after takeoff, the single pilot lost control of the aircraft. The radar track showed
the aircraft climbing through its assigned altitude and then flying erratically before plunging into Lake Erie with a descent rate
of about 6,000 feet per minute.
The pilot had been awake for 17 hours at takeoff. He had recently transitioned from another small jet and completed aircraft
and simulator training, resulting in a single-pilot type rating only three weeks before the accident. According to his instructors,
he had been taught to operate using the autopilot most of the time. He may have suffered from mode confusion regarding the
configuration and status of the autopilot in the new aircraft, and may not have verified autopilot engagement. He may also have
experienced external pressure to return to Columbus that evening.
Risk Identification, Assessment, and Mitigation
Several categories on the PA VE checklist may apply to this accident. The pilot may have been fatigued. It is likely that his
expectation and that of the passengers was to return to Columbus immediately after the event. After departure, he may have
unconsciously applied procedures appropriate to his previous experience. The nighttime environment and departure over the
lake required the pilot to both monitor the flight instruments and deal with the automation.
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The catastrophic consequences associated with this accident, when combined with at least occasional likelihood, created a high-
risk level for loss of control. In hindsight, having a second pilot or “mentor pilot” for this flight may have reduced the likelihood
of loss of control. In addition, remaining overnight in Cleveland would have provided needed rest for the pilot and allowed for
a departure during daylight, which also could have reduced the likelihood of loss of control.