Looking back over the past columns I see that the subject has become quite "heavy", full of theoretical concepts and complicated philosophies. Also, jumping out of the pages is an overall impression of just how bad/incompetent/illogical the human being can be. In fact it looks like we should never be in an aircraft in the first place!

Is this real? Of course not. Flying is not as complicated as that, and humans all over the world fly millions of hours each day without incident. Most airline pilots finish their careers without any mishaps or even "near misses". So why this focus on accidents, what pilots did wrong, what our failings are? Perhaps because accidents are almost always reported andto scrutiny. We have a morbid preoccupation with death and destruction and an aircraft accident is always subject to an official investigation and report. A byproduct of this is that we have the opportunity to learn from the well-documented mistakes of others.

But what about the ones that don’t make the headlines and reports? What about the good decisions that were made, the accidents that did not happen because of good judgement and airmanship? Are these not as valuable as an accident analysis?

Yes, perhaps even more valuable, as the survivors are there to tell their stories! Unfortunately this information often stays buried because most often there is no easy way to share the information with other aircrew. Maybe if we were able to tell others about how we successfully handled abnormalities or emergencies in flight we could all learn from them.

"How?" I hear you ask. True story. Perhaps it is time toup the Internet to Mr. or Ms. Average Pilot, starting a site for "I learned about flying from that" stories. Are you listening Carey?

Captain Jaco de Beer, a SAA Training Captain, is investigating this aspect in a dissertation for his MBA. He asks the question: "How do we share the important lessons that pilots learn every day? We don’t gather in the pub behind the hanger to discuss the events of the day, like we used to a hundred years ago. If new ways of sharing knowledge holds part of the answer, how do we capture, manage and achieve real benefits for the airline from managing this body of knowledge?"

If you have any ideas on how we should or could be sharing information, please contact Jaco at

I will also pass on any information to him.

I would really like this column to be interactive. Please let me know what you think of the concepts and philosophies I espouse here. You don’t agree? You do? Mail me at

So, with that off my chest, let the column begin – a much lighter and less complicated issue this time, dealing with what pilots did right!

In the previous columns we were investigating some of the psychological aspects of our operation as pilots. We saw how susceptible we are to stress and distraction and hopefully learned some tricks on how to overcome these limitations.

In this column I will touch on an important concept, risk management.

Surely it is better to avoid risk altogether, then you don’t have to manage it? True. However, flying alone is a risky business, just like money management. Putting the money under the bed carries some risk, just as any flying carries a certain amount of risk. What we have to do as pilots is

• minimise the risk from the start
• avoid risk during the flight
• manage risk when we can’t avoid it
• manage the consequences of having taken a risk.

Let’s deal with each in turn. Remember, most problems arise as a result of a chain of events or decisions. In a later we look at poor judgement chains, but we will start with the concepts here.

As I mentioned in Column #2, many errors are avoided and trapped before you even start your preflight, and you are thus able to begin minimising risk right then.

Some examples of risk limiting preflight actions are given below.

• Use the IMSAFE personal checklist to make sure you are up to speed. This checklist is very well know and not discussed here.

I Illness

M Medication

S Stress

A Alcohol/drugs

F Fatigue

E Emotion

• Flight planning and weather briefing. Flight planning is more than drawing a line on a map! Develop your critical thinking techniques!

• Spend some time looking at the proposed task and route, building up a general knowledge of the terrain and en-route and destination diversion airfields – just in case you need to deviate from your plan!
• Try to imagine how the forecast weather will affect your trip, how "unforecast" weather would affect your flight. Can you trust the forecast?
• Decide on "critical areas" en-route, such as crossing the escarpment, crossing a large expanse of uninhabited land, or entering a very busy TMA. Plan accordingly!
• What are you going to do if your destination becomes unattainable?
• How much fuel do you need? How much extra do you need/want? Can you refuel en-route if you need to? Where?
• Check NOTAMs, AIC, also phone Flight Briefing to obtain up to date information.
• ATC flight plans and overdue action needs some consideration, too.
• Weight and balance planning. Loadsheet correct and a copy stored with the operator?

• Aircraft preflight. You must be confident that the aircraft will do its job, if not, no go. If there is any doubt, there is no doubt!

• Look at the past maintenance history of the aircraft. What recent snags has it had, how well were they repaired? What is the serviceability like now? Speak to the last pilot if possible.
• Check all the equipment – First Aid, strips, fire extinguisher, water bottle and other survival necessities. Check the lights, clean all the windows as part of a good preflight.
• Weight and balance OK? Loading of bags, pax to remain within CG?

• Pre-start checks. Many accidents are caused by one or more of the following actions, and the preflight is no exception.

• Have you done everything you need to do? Spend a couple of minutes running through a mental checklist before you turn the key. Obviously the flying stuff (map, flight log, flight plan, pen, paper, etc.). Also destination requirements (car keys, cell phone, etc.), All to ensure that your mind stays on the job!
• Are you feeling in a rush? Walk around the aircraft a couple of time, go to the toilet, anything to slow you down.
• Brief your passengers. Seatbelts, airsick bags, escape routes, evacuation techniques, grab handles (not the column!), other information relevant to the flight (cold, heat, altitude, bumpiness, duration, etc.). Explain the requirements to avoid distraction during takeoff and landing, but also the need to point out to you things that don’t seem right.

Is everything going according to plan? Great! Bored? No, too busy looking out for forced landing fields, keeping my situational awareness up by looking out, listening out on the radio, doing instrument and fuel checks, map reading. You are limiting risk. Checking fuel might trap an error, good mapreading and "field spotting" might save the day if your engine fails. All good stuff.

Something goes wrong? Bad weather at destination, large thunderstorm on track? Engine starts running rough? Slightly lost and the darkness catching up with you? Report from ATC of cloud over the escarpment? Sick passenger? All of these situations will start to put pressure on the pilot, will demand some decision-making and will often require an alternative plan. Most often the decisions to be made will involve a choice between different options, a form of balancing risk.

Let us take an example and try to build a "Risk Management Model" (RMM). A typical RMM model would hinge around 3 core and sequential elements:

Petra Nella has planned to fly her light twin back to Lanseria from Durban where she has been visiting. She planned to take off with 2 hours of sunlight light left, so that she would be over the high ground of the Natal highlands in the light, and be in a position to complete the last hour or so in the dark, but over the "flat" highveld.

Good thinking. Even though she has a night rating, being over the high ground in a light aircraft is not a great idea, leaving too few alternatives in an emergency – minimising risk.

She filled the aircraft’s main tanks, giving her 4 hours of fuel. She left the tips empty to give her some extra performance capability in the case of an engine failure.

Debatable? Here Petra has to balance one risk against the other. With full tanks the aircraft will perform poorly on one engine, especially over high ground. However, having limited fuel on the other side is not great. Which do you choose? Depends on the weather, the aircraft, your personal risk aversion! What do you think?

The weather forecaster was going in for clear skies along the coast, scattered cumulus cloud over the escarpment and broken medium cloud over the Highveld. There was a 20% probability of isolated thundershowers over the Highveld and escarpment. The Highveld weather was forecast to improve to CAVOK after sunset, with a small possibility of fog the next morning. The winds were forecast to be fairly strong easterly, and the expected winds for Lanseria easterly at 15kts.

Sounds OK? Sure, no problems. Risk limiting means looking past the obvious, taking forecasts as just that, not the truth! The weatherman has been known to be wrong in the past! The weather on the escarpment also changes very rapidly. Heard about Guti fog? This fog and/or low cloud sometime occurs when the wind is easterly and moist. The forecast called for morning fog, so be alert! Do you carry a bit more fuel for that? Again balancing risk. What about storm avoidance, more gas? What would you do?

She completed a good preflight, making sure she had some emergency rations and a comprehensive first aid kit. She also borrowed a hand-held VHF radio and a set of mini-flares. She briefed her 2 passengers comprehensively on what to expect, and they all had a light meal prior to departure. A last minute visit to the toilet and they were on their way.

Improving chances of survival should something go wrong is always commendable. Redundant radios and flares at night also a great idea. Risk limiting.

The takeoff was normal, and the aircraft was soon cruising comfortably at FL105 with a very nice tail wind, thank you. There was some scattered cumulus cloud just at the flight level, and Petra was quite busy dodging the bumps. There was one isolated storm in the Greytown area and she had to deviate 15 miles south of track to avoid it. She was tempted to descend below the clearly defined base of the storm, avoiding the rain. This would have saved her some time, but she elected to be cautious. She scanned her engine instruments carefully, noting down on her flight log the positions of each of the needles or the reading on the gauges.

How about descending to FL085 to avoid the cumulus? Bumpy. Climb to FL125? Oxygen. Not many options here. How about her thunderstorm avoidance? Underneath often looks good, but beware, there may be hidden dangers (rain, hail, windshear, lightning, etc). When there is any doubt …… Avoiding risk!

Why make a note of what the gauges are reading? Well, in times of stress, you will know where the gauges were, and can compare them to where they are now! Trend monitoring is always a good idea, especially on long, boring trips. Then you are sure to spot something happening long before it happens.

3. Manage risk when we can’t avoid it, and managing the consequences

Around Harrismith (close to half way) the left engine began to run rough. Petra made sure the autopilot was functioning correctly, increased power on the "good" engine to climb power and started to troubleshoot. She checked the engine control selections, fuel tank selection, checked the mixture setting and the alternate air control. She went back to the aircraft instrumentation and checked that the aircraft was maintaining speed, direction and height. She then scanned the engine instruments for any signs of abnormality. Nothing abnormal. She compared the readings to those made at the last checkpoint. No unusual trends.

She reduced the power slightly on the "bad" engine and the vibration increased. Changing the pitch setting also increased the vibration. She tested the magnetos individually, this having no effect.

Baffled, Petra double-checked her engine control settings, trying to find a setting that would eliminate the vibration. She looked at the cowling but could see nothing unusual. She contemplated trying to cross-feed the fuel from the "good" side fuel tank in case the fuel was contaminated, but decided against that. She reduced the power to about 50% power on the "bad" engine by reducing the throttle and reducing the RPM to the lowest permitted for cruise. She was hoping that the lower RPM would result in less vibration. Her passengers were beginning to look a little worried, seeing Petra busy checking all the controls and instruments, but she was quick to reassure them.

Petra applied the RMM principles well here.

Assess: What has happened? Rough running engine. No immediate panic, time to think.

Action: Fly the aircraft. Monitor the autopilot (engage it if possible), manage the performance of the aircraft, manage the good engine. Start troubleshooting. Keep troubleshooting, using a bit of lateral thinking.

Manage: She kept her head, not overreacting. She made sure the aircraft was flying efficiently while she troubleshot the problem. No immediate drastic action was necessary, so she paced herself through the required actions and then started the process of decision-making.

How about the idea of transferring fuel from the one side to the other? The old saying goes "if it works, don’t fix it". The good engine is doing well. If you can’t positively identify the problem, then try to maintain the status quo for as long as possible. Do you agree?

It is important to know that the RMM allows you to keep doing the assess/action/manage process until everything possible has been done and the situation stabilized. See again below.

Decision-time! She started to look at the options available to her, putting her thoughts down on paper, keeping an eye on the instrumentation and engine instruments at the same time.

Options:

• To return to Durban?
• To continue onto Lanseria?
• To divert to the nearest airport?
• To descend to a lower level or to climb?
• To shut the engine down or keep it running?

To start the process off, Petra contemplated descending to a lower flight level as a result of the lower power produced by the left engine. She was aware that the highest ground was behind her, so she spoke to ATC and requested a lower cruising FL.

This is the "manage" part of the RMM. It is critical that this type of decision-making be done correctly. Under pressure, one may easily make a hurried (and incorrect) decision, the first solution that comes to mind. This solution might be quick and simple, but may not be the best. It would pay to start a little "mind map" of the situation, as this will structure your thinking and thus your decision-making. Petra did this and made he decisions based on her assessment of the risk of each option.

Now she decided to "hurry slowly" and began gathering information.

• She contacted ATC and informed them that she had a vibration on one engine and that she had to make a few decisions.
• She asked for, and obtained, the latest actual weather for Durban, Lanseria, Johannesburg International and an updated area forecast for the escarpment area.

Her decision-making technique is good. She "confesses" her problem to the ATC, giving accurate and clear information about what her problems are. She uses the ATC resources to obtain the weather that will aid her in her decision-making.

Back to the flying. Performance OK, although she noticed that her groundspeed was about 25kts lower than planned. She also noticed that the fuel flow on the "bad engine" was much higher than it should be at the low power setting, and her attempts at leaning the mixture had no effect.

This generated another thought process – fuel management. 25kts (about 20%) down on groundspeed with same power means 20% reduction in range. Oops. This could prove to be problem. Some mental arithmetic showed that she would now be eating into her 1-hour of spare fuel if she continued to Lanseria.

Risk management decisions now come into play. Is it more risky to head back to Durban than continue to Lanseria/Johannesburg? Should she head for Harrismith or another small country airfield nearby? What about shutting the engine down?

Looking at the options available to her, Petra decided on a PAN call and declared her intention to continue initially for Johannesburg International. She decided to fly via a number of airfields en route, just in case the "bad" engine became worse. She also notified ATC that she would like to continue to Lanseria if the situation was still stable when she got closer to Johannesburg International. She decided not to shut the engine down.

Petra is able to alter her planning if something in the environment changes. She pays close attention to detail, so she notices the fuel problem before it becomes and emergency. This is part of Assess. She calculates ahead, looking at how her options have changed. She now completes the Action part – making a decision based on the new information. The Manage side is important: she declares to ATC that she has a problem and gives them her intentions. She knows that it would be better to go to destination, as this is where the maintenance facilities are and also where they want to be. However, she knows that "press-on-it is" breaks aircraft, so she makes contingency plans just in case the situation deteriorates. Would you regards this as good thinking?

Her decision not to shut down the engine? Well, this would really commit her to a landing at the nearest suitable airport. She reasoned that if the other (good) engine failed, she would still have the "bad" one going to assist her with continued flight. What is your opinion?

The flight continued uneventfully. Petra took out her checklist and reviewed the engine shutdown procedures "just in case". Passing south of Johannesburg, Petra noticed that the fuel flow had begun to fluctuate on the bad engine, and it began to surge and backfire.

Murphy is alive and well and patiently waiting for a good time to surface! Try to pre-empt him where possible, and fill in the dead time with a review of procedures.

Petra notified ATC briefly of her requirement for immediate descent and took manual control of the aircraft, completed the engine shutdown and re-engaged the autopilot. She declared an emergency requesting vectors for Johannesburg International. Amid great excitement, Petra landed and was escorted to the maintenance organisation by a large fire engine.

All is well that ends well. Assess – engine failure (anticipated). Action – do the required checklist, secure the engine, maintain efficient flight. Manage – proceed with plan C.

Do you have any comments on the case study?

This column has attempted to introduce you to the RMM in the form of a success story. Obviously there are a number of different models around, but each will have similar techniques and goals in mind. If you have a favourite one, I would be happy to include it in the next column!

Good risk management!

Mike Malherbe

Mikemal

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