In episode 5 of Flight Podcast we talk with John King of King Schools. Kings Schools has a hand in training over 50% of the pilot population in the United States at some point in their career via a library of over 90 courses that can be completed using interactive DVD’s or online via their proprietary learning management system. The global operation is managed by John and Martha from their San Diego headquarters with the assistance of about 75 staff.
I’ve always been a fan of John and his efforts to raise awareness of aviation safety – particularly that of private pilots in general aviation – so it was an absolute joy to talk to John about Risk Management, Threat and Error Management and Decision Making. Incidentally, we spoke to Dick Rutan in episode 6 who – after telling us tales of a career spanning over 40 years – talks about decision making and the risks involved in letting emotion cloud otherwise logical decision making. The two episodes are quite complimentary. Of course, the schedule of Dick’s episode may vary slightly based upon a chat we’ve had with a pilot that ties in more closely with recent and current events.
John’s not afraid to address specific issues of concern. In his opening statement he makes a referenced claim that, despite popular belief, aviation is dangerous. He states that we are seven times more likely to die in a light aircraft than we are in a motor vehicle, and most of these accidents might be prevented by applying more effective risk management strategies on the ground as part of pre flight planning. Who hasn’t heard of the 5 “P’s”? Prior Planning Prevents Poor Performance. John advocates that pilots become more prudent with preflight choices so as to eliminate the need to make much more difficult in-flight decisions.
John tells us that effective decision making begins with a somewhat pessimistic anticipation… or thinking about what could potentially go wrong well before it does (he calls it being a cockpit conservative). He says that be maintaining a mental lookout during preflight preparation we’re better positioned to identify in-flight threats when they present themselves, and we’ll be in a better position to mitigate our behaviour.
“Superior pilots use their superior judgement to avoid situations requiring the use of their superior skills” – Anonymous
John tells us what most professional pilots already know: “…the way we teach risk management in aviation is flawed… the problem with learning by experience is that the test comes first and the lesson comes afterwards. Many pilots and their pilots never survive the test to learn the lesson”.
John and Martha have developed a simple risk-assessment mnemonic for pilots to incorporate into their pre-flight planning – PAVE. It’s designed to assist pilots in identifying personal and external pressures and/or limitations that may adversely impact upon a successful flight.
P – Pilot (illness, fatigue, limitations, pressures etc)
A – Aircraft
V – Environment (weather, wind etc)
E – External pressures (get-there-itis, meetings, passengers etc)
PAVE essentially forces pilots to consider various risks associated with their flight so they’re in a better position to mitigate behaviour and avoid using those “superior flying skills”.
Pilots are goal orientated people; we have a destination and we often believe that we have the skills to get there despite weather and circumstances potentially conspiring against us. In episode 2 of Flight Podcast we spoke to Andy Thorley who planned to fly an ultralight from northern New South Wales to a small private strip about an hour drive west of Sydney. To end a long story, Andy found himself over the suburbs of Sydney at night (in an aircraft without lighting or certification in anything other than daylight conditions) with low fuel. His aircraft ultimately ran out of fuel and Andy was forced to make an emergency landing in a field in complete darkness. Andy’s trip is a good example of Reason’s Model in action (Swiss Cheese Model). He had countless opportunities to identify the risks of continued flight yet his goal (or mission) orientated behaviour led him to believe that he had the ‘superior skills’ necessary to reach his intended destination.
It was interesting that Andy referred to his flight as a mission from the beginning of our talk. “Mission” is a military term that normally relates to a pass or fail task – normally implying death or defeat in military terms. In general aviation we don’t undertake missions… we go on “trips”. Departing with a mission mindset, or adopting a mission mindset during a flight when presented with mounting adversity, increases risk.
We recently wrote about a Red Bull Air Race competitor, Matt Hall. Matt had posted a stream of messages to Twitter and Facebook on the morning of a flight broadcasting an illness he hadn’t completely recovered from. He posted, “…feeling a little better today, though still very fatigued. Looking forward to 2 successful flights, then off to bed.” A few hours later he was lucky to escape death when he g-stalled his aircraft off a knife edge manoeuvrer and impacted water in front of family and spectators. Matt impacted the water relatively flat so ‘bounced’ off and managed to recover. Had he applied John’s simple checklist he would have been forced to assess both his illness and fatigue. Clearly, he wasn’t fit to fly. It’s also likely that Matt knew his competency was compromised by illness but decided to fly anyway.
Matt Hall is an ex military fighter pilot so it’s quite possible that his military style “mission” mindset translated into his civilian (career) flying. It’s also fair to say that the nature of sponsored competitive air racing meant that a mission mindset would have applied anyhow. A dangerous mix.
PAVE is intrinsically connected with the principles of Threat and Error Management (TEM). What is threat and error management?
Threats are events or errors that occur beyond the influence of the line personnel. They increase operational complexity and must be managed to maintain the margins of safety.
Errors are generally defined as actions or inactions by the line personnel that lead to deviations from organisational or operational intentions or expectations. Unmanaged and/or mismanaged errors frequently lead to undesired states. Errors in the operational context thus tend to reduce the margins of safety and increase the probability of an undesirable event.
Undesired states are generally defined as operational conditions where an unintended situation results in a reduction in margins of safety. Undesired states that result from ineffective threat and/or error management may lead to compromised situations and reduce margins of safety aviation operations. Often considered the last stage before an incident or accident.
Does TEM have a place in general aviation? Absolutely. In fact, TEM was introduced as part of Line Operation Safety Audits (LOSA) flights where crews would be assessed on CRM and, to a lesser degree, physical operation of the aircraft. In general aviation we have Biennial Flight Reviews (BFR’s) where an instructor essentially does the same thing. Instructors have an obligation to ensure that they don’t simply assess a candidate on ‘flying an airplane’… they should ensure that the candidate applies a range of principles that enables them to better ‘manage an aircraft’.
It’s easy to let somewhat academic concepts cloud otherwise obvious principles. When we spoke to Andy about his ultralight incident he claimed that these TEM principles either didn’t exist or weren’t taught at the time of his incident. Sure – that is partly true – but risk management is something that ‘professional’ pilots have always considered. It takes me back to Eric Moody’s comments with reference to CRM – “common sense and airmanship are not that far apart.”
Failing proper planning or preparation, or as a result of a threat that wasn’t considered or known at the time of planning, it’s often necessary to implement a formal decision making model to assist with making a choice the best decision that will lead to the safest outcome. We talked to John about decision making models but we reverted back to simple risk management strategies after John made it clear that this was an area where most pilots make the majority of mistakes.
I’ve often believed that private pilots can often find themselves perpetually un-current… or dangerously safe. They often find themselves, to quote Top Gun, “writing cheques their body can’t cash”. Personally, I’m sick of hearing fancy sayings, simple expressions and rules of thumb as a means of true and effective risk management. Flying can be dangerous, and the risk of error is often inversely proportional to the attitude of the most likely ‘component’ in the aircraft to fail – the biological lump sitting in the hot-seat.
It was an absolute pleasure talking to John about some of the serious deficiencies in general aviation safety. John’s had over 40 years involved with all facets of aviation with an emphasis on training and safety. When he speaks up the way he did, it’s in the interest of all of aviation to listen. To ensure you get a link as quickly as possible, we suggest you subscribe to the Flight Podcast mailing list or subscribe to our program us in iTunes.
You can read the show notes for episode 5 from FlightPodcast.com.
- Single Pilot CRM – A pilot runs out of fuel at night in an Ultralight
- Airtime : CASA’s Crew Resource Managament Training Toolkit
- Flight Podcast Episode 2
- Matt Hall’s Red Bull Near Miss. Fit to Fly?
- Instrument Flying: Classroom, Week 1
- Bo Corby & NWA Flight 41 (Podcast)
- Decision Making Models in Aviation