TTCF Flight risk Assessment Tool by Bob Thomason, Editor

Transcription

1 TTCF Flight risk Assessment Tool by Bob Thomason, Editor History Last month we announced the formation of a team to develop a Twin Cessna Flight Risk Assessment Tool (FRAT). We have completed the process and you can find a copy of the completed tool on our website at Historically, The Twin Cessna Flyer has never had an official Safety or Pilot Proficiency program as some other type clubs do. One reason is we feel that all twin pilots should attend some sort of simulator-based training annually. That plus the systems knowledge gained from our own Systems and Engine courses can give a Twin Cessna pilot a tremendous leg up on proficiency. For those pilots who want training in their own airplane, we have an excellent cadre of instructors available to us who specialize in our aircraft. Their names and contact information are listed in the Classified section of each magazine and on the website. We recently decided to augment this approach to safety by developing a TTCF Flight Risk Assessment Tool as our first step. First some background on FRAT s. What Is a FRAT and How Is It Used? A lot has been learned about risk and safety in the last 30 years. This is particularly true of aviation. Think about the incredible safety record of the large schedule air carriers. The same is true of other industries that utilize complex equipment. Historically, accidents happened, causes were determined and procedures were developed to prevent the same accident from happening again. Over time, safety-conscious industries began to become proactive in their approach to risk, identifying areas of risk in advance and developing procedures to mitigate those risks. Using this approach, safety began to improve dramatically. This business-like, proactive approach to risk management resulted in the development of formal Safety Management Systems (SMS). Documented SMS s are now required by the ICAO for large commercial air carries operating overseas. The FAA 20 TWINCESSNA.ORG is engaged in a rule-making process that may extend the requirement to commercial carriers the U.S. To learn more about SMS s and aviation see: sms/ The Flight Risk Assessment Tool is one small part of an aviation SMS, but a part that is immediately applicable to our operations as Twin Cessna pilots. Simply put, a FRAT is a risk checklist that incorporates a method for: 1) identifying individual risk factors that apply to a particular flight and 2) estimating the total risk involved in making the flight. To use a FRAT, a pilot simply notes all the risk factors present, lists the corresponding Risk Value (a 1 to 5 scale) in the rightmost column and adds up the total Risk Value Score. If the score is greater than 25, we (continued on page 22)

2 TTCF FRAT (continued from page 20) recommend the flight be scrubbed or that individual risk factors be mitigated to reduce the score to an acceptable level. That said, we recognize that all pilots approach risk differently and different pilot capabilities influence how much risk a certain factor entails. Therefore, consider this tool a starting point for your own personal FRAT. Modify it to fit your experience level, your equipment and flight profiles. And one more caveat, nothing in the tool is meant to supersede FAA regulations or your Aircraft Flight Manual instructions or recommendations. It is assumed that for every flight, you, your airplane and your planned flight are in full compliance with the FAR s. TTCF Tool Development We assembled a team of five TTCF members and advisors to develop our Twin Cessna FRAT. The team names and bios are listed on page 6 of the April issue. Our combined experience includes: over 30,000 hours total flight time over 10,000 hours of Twin Cessna flight time 2 active CFII s and Twin Cessna flight training specialists 1 Twin Cessna maintenance specialist with 30 years experience For our starting point, we all did our own individual research, reviewing accident reports and drawing on personal experience. We then began with the generic FAA FRAT. This tool required considerable customization since it was developed for professional 2-pilot crews flying turbine equipment. We went through this tool line-by-line and adapted it for our airplanes and the type of flying most of us do, by choosing the individual Risk Factors and assigning Risk Values. In spite of each of our individual experience levels, it was an incredible learning process to hear everyone on our team share their perspectives on risk. The process of thinking through the tool helped each of us fine-tune our thoughts on flight risk. In this article, and several that will follow, we will share our thought process on each line item of the tool. This article will address the No-Go/ Personal Minimums page and the Pilot Qualifications section. Future articles will address the Operating Environment and Equipment sections. No-Go/Personal Minimums Page First things first. If you, your airplane or your planned flight are not in compliance with the FAR s, there is no need to complete the FRAT. Your flight is scrubbed until you correct the deficiencies. The same applies to your personal minimums. If they are not met, you don t fly. Assuming these minimums are met and all regs are complied with it s on to the FRAT risk factors. Pilot Qualifications and Experience Section The first thing you ll note about this section is the high individual risk values. All are 5 s, the maximum value, except for one 4. They are higher, on average, than those of the other sections. Why? Two words: Pilot Error - the cause of the vast majority of general aviation accidents. Our review of Twin Cessna accident reports revealed a high number where the pilot had either low time-intype or a lack of recent experience and, in many cases, both. #1: Less than 200 hours in Type. Risk Value =5. Again, one cannot read the accident reports and not conclude that low time-in-type is a huge risk factor. The insurance carriers have stringent requirements for pilots transitioning to Twin Cessnas but regardless, it takes considerably more experience to become truly comfortable and proficient. One accident report we reviewed included a 414 pilot who perished on the very first flight after flying off his 50-hour insurance company mandated dual instruction. Our group felt it takes roughly 200-hours in type before the risk level stabilizes. In this case, we agreed with the FAA value. #2: Less than 30 hours in the last 90 days. Risk Value = 5. How much we ve flown recently affects our proficiency. We ve all felt rusty after a period of not flying. Professional pilots often say the rust is apparent after as little as one week out of the cockpit. This line item is an attempt to measure the rust factor. The FAA tool says 100 hours in the last 90 days is appropriate (400 hours a year). Few Twin Cessna Pilots fly that much. Most of us fly in the 100 to 120 hour per year range. We know we d be more proficient at 400 hours a year but we accept the risk of reduced flying. Our team felt with less than 30 hours time in the last 90 days, we begin to incur some additional risk. #3: No type-specific recurrent training in the last 12 months. Risk Value = 5. A BFR is really not enough. Every Twin Cessna pilot should have annual recurrent training either in a simulator or in your airplane or both (best). You simply must practice handling engine out situations if you are to have any realistic hope of successfully handling one in real life. Additionally, most every pilot can benefit from an IPC annually. Those of us who fly a lot may have no problem staying legally current on instruments - but it s mostly by shooting a lot of ILS and GPS approaches at familiar airports with an occasional hold or missed approach. Only recurrent training gives us practice shooting unfamiliar NDB, VOR or circling approaches with their step downs and dog-legs that often trip us up. #4: Duty day exceeds 14 hours. Risk Value = 4. Flying at the end of a long day entails greater risk. How much depends on what you did during the day. Attend business meetings? A football game? Nap at your in-laws 22 TWINCESSNA.ORG

3 house? Ultimately, you are the judge but, regardless, if you are flying 14 hours after you woke then you are probably not as sharp as you were earlier in the day. The FAA tool specifies a 12- hour duty day, so we liberalized this a little, recognizing that most of us are not professional pilots and are not necessarily working between flights. Our tool doesn t address this directly but if you are flying at a time when you normally would be sleeping (early AM or late PM for most of us), the risk goes up as well. Studies show our body tends to preserve it s internal rhythm and goes into a lower state of alertness at these times. #5: Feeling tired, ill or under stress. Risk Factor = 5. In many cases, this might be a no-go item. If you are not functioning at your normal level, for whatever reason, it s probably a good idea to scrub the flight. But ultimately you are the judge. A short, routine VFR flight before you ve completely recovered from that cold you had might be OK. A long, IFR flight to an unfamiliar airport with a likely instrument approach at the end would not be advisable. We are on the honor system but the stakes are high. An observation: the accident reports are full of pilots who perished while having various levels of disqualifying drugs in their system - both prescription and nonprescription. It s important to know what is allowed and what isn t. You may not think the drug affects your ability to fly, but the accident reports may say otherwise. Be conservative here. The pilot is the one part of the system that has to be squawk-free. #6: External pressure to complete the trip. Risk Factor = 5. Getthere-itis has killed many a pilot and his passengers. If you are under pressure to make the flight, you are at great risk, period. It will affect your decision-making should any challenging issues arise. The good news is that this risk generally can be mitigated by thinking ahead and creating what one of my instructors once termed solid gold alternate plans. What if you get in your airplane and one of the engines won t start? What if you can t fly home the day you planned? Will you drive? Take the airlines? Wait a day? Think all this through in advance and do what you can to make the alternative palatable. I m a huge believer in visualization. So when I m thinking through my alternate plans, I visualize myself renting the car and getting my hotel room for the evening. It makes the actual decision much easier to make if I ve already made it. Another tip that s worked for me over the years is managing passenger expectations. If the weather looks questionable a few days before the trip, I ll give the passengers a heads up. In my charter flying, I would also give them a probability estimate: e.g. there s a 20% probability we won t be able to make the trip on Wednesday. If I thought there was a 50% chance or greater that we couldn t fly, I d suggest they develop a backup plan for their trip. At that point, the pressure was off me and on them. Not once in my flying career have I had a passenger express dissatisfaction with conservative decisionmaking even though most of the trips I ve cancelled could have been flown safely. Here s a sad story to illustrate this risk factor. A 414 took off from an uncontrolled field at night in low weather. It crashed about a mile off the end of the runway, killing the pilot and his 2 passengers. In the prior 24 hours he obtained 17 weather briefings. What would make a pilot attempt this flight when he was clearly so concerned about the weather? A solid gold alternate plan might have saved his life. Next month, I ll discuss the Operating Environment section of the FRAT. In the meantime, download the tool from our website, customize it as need and begin using it. THE TWIN CESSNA FLYER MAY

4 TTCF Flight risk Assessment Tool - part 2 - part 2 by Bob Thomason, Editor What if you had an instrument on your panel that very accurately showed you the risk involved in making a particular flight? What if you started your airplane, flipped on the avionics master and saw the picture to the right? Would you go flying knowing that what the instrument was telling you was that a lot of pilots have died trying to make a similar flight? Hopefully, you d try to determine what was making the flight so risky and then mitigate some of the risk factors. This is the idea behind the Flight Risk Assessment Tool. Last month we introduced the Twin Cessna Flyer Flight Risk Assessment Tool (FRAT). We discussed this history of its development and explained how these tools are being adopted by professional flight departments worldwide. We discussed the Pilot Qualifications and Experience section in detail. In this issue, we ll review the next section: Operating Environment. The Operating Environment section contains the greatest number of risk factors of any of the three sections. This makes sense as there are so many variables associated with the environment in which we fly. However, some of these variables raise the risk level of a flight more than others so the risk values assigned to them vary more than do the Pilot Qualifications and Experience risk values. Generally, anything that impacts the ability of the pilot to fly the airplane has a big impact on risk, whereas a challenge in the operating environment may have a smaller risk factor particularly depending on the capabilities of the pilot or aircraft. Let s dive into this section. But rather than discuss each risk factor, I just want to highlight a few that require explanation. And remember: nothing in the tool is meant to supersede FAA regulations or your Aircraft Flight Manual instructions or recommendations. It is assumed that for every flight, you, your airplane and your planned flight are in full compliance with the FAR s. #7: No published approach. Risk Value = 3. We debated this factor quite a bit. Some of us felt it was too situational. 20 TWINCESSNA.ORG That is, on a clear VFR day with no IMC within a couple hundred miles there s not much risk in launching towards an airport without an instrument approach. On the other hand, the accident statistics show a significant number of (continued on page 22) Would you make the flight if your panel mounted Risk Meter looked like this?

5 TTCF FRAT - Part 2 (continued from page 20) accidents involving pilots trying to land in IMC at airports with no approaches. One example: An air ambulance pilot flying a 340 was attempting to return a nurse to the uncontrolled, no-approach airport where the nurse s car was located. He crashed in ground fog, killing both of them. The NTSB report noted that on the glareshield were charts for two nearby airports that had instrument approaches. This type of accident should never happen but it does with some regularity, so we included it as a risk factor. #9: Circling Approach - Day (Night) Risk Value = 3 or (5). It is generally accepted that circling approaches are the riskiest instrument approaches. And circling approaches at night compound the risk. Remember, if you are at circling minimums, at most airports that will be well below pattern altitude. The visual picture is much different from what we re normally used to and things can go wrong in a hurry. When was the last time you practiced a circling approach? Our team debated on just how much additional risk is incurred. Many flight departments prohibit night circling approaches. We gave them the maximum risk value but several on our team felt a flight that would knowingly end in a circling approach at night would be a no-go. I was one of them even though I practiced them regularly and performed them twice a year on FAA checkrides. #10: No weather reporting at Destination. Risk Value = 5. We also debated this risk factor. Some of us felt the actual risk varies considerably depending on particular circumstances. What if the nearest reporting station is only 5 miles away? What if it s 50 miles away? What if you will have 2 hours fuel remaining when you arrive? Or just 45 minutes? But the bottom line is if there is if no weather reporting, you can t really know what the weather is. We had the same debate about #11: Alternate Not Selected. The risk is highly dependent on the circumstances. When our team disagreed, we opted to go with the most conservative opinion which we did in both of these cases. 5 is also the same risk value the FAA chose on its template tool, indicating some statistical validation. #13 through #17: Ice, Thunderstorms, Severe Turbulence, Winter and Night Ops: the risk associated with these factors is obvious and confirmed by accident statistics. No further comments from our team. #18: High Terrain Surrounding Airport. Risk Factor = 3. The FAA uses the phrase Mountainous Airport. We ve read so many accident reports of airplanes colliding with hills (high terrain) around airports in non-mountainous terrain that we felt it was important to make this distinction. Most pilots are on high alert when flying in mountainous areas. They seem to sometimes be lulled into complacency when in flatter country. The classic accident is a pilot departing into marginal VFR and then having difficulty picking up an IFR clearance. He flies around waiting for ATC to respond and hits something. The lesson is, of course, to always know where you are relative to the surrounding terrain (and to get your clearance on the ground, if possible, when in marginal conditions.) #19: Runway length < accelerate/stop distance (if unavailable, use takeoff distance plus 1/2 landing distance). Risk Factor = 2. and #20: High density altitude and maximum gross weight takeoff. Risk Factor = 5. Short runways limit options, particularly if anything goes wrong. It is important to do a weight and balance and takeoff performance calculation whenever runway length might be a concern. The very best option for dealing with an engine failure on takeoff is to cut the power and land straight ahead - if there is runway available. The shorter the runway, the less time the pilot has to exercise this option. While we don t yet know exactly what caused the 310 accident in Palo Alto, CA (KPAO) in February of 2010, we do know that the pilot and his 2 passengers departed a 2,450 foot runway in IMC conditions and veered left instead of right as called for in the Departure Procedure, hitting power lines and crashing close to the airport. If an engine problem was a factor, the short runway eliminated any chance of cutting the power and aborting the takeoff. And don t assume that just because you ve used a short runway before, you ll get the same performance when you use it again. A 320 pilot in FL routinely used a 3,000 ft. turf strip with the same passenger load. On one particularly hot day, he mushed into the trees after takeoff, killing one of his passengers. A review of the performance data from his POH would have warned him of the degraded performance that day. Using short runways definitely increases flight risk. #22: Planned flight into last hour of fuel. Risk Factor = 3. Fuel exhaustion is a continuing cause of Twin Cessna (and all GA aircraft) accidents. Detailed fuel and range calculations, conservative alternate selection and enroute monitoring of changing weather conditions are critical. With a nod to the wisdom of aviation writer Richard Collins, we favor this one simple guideline: if you are flying in your last hour of fuel, the risk increases. Plan carefully for it. No FRAT can be a true one-size-fits all document. Each pilot will need to customize it to his/her particular skills and aircraft. But experience shows that using a FRAT can decrease the risk associate with your flying. The pros do it and we should too. Download the tool from our website, customize it as need and begin using it. Next month, we ll discuss the equipment section. 22 TWINCESSNA.ORG