17-1

Introduction

Aeronautical decision-making (ADM) is decision-making 

in a unique environment—aviation. It is a systematic 

approach to the mental process used by pilots to consistently 

determine the best course of action in response to a given set 

of circumstances. It is what a pilot intends to do based on the 

latest information he or she has. 

Aeronautical 

Decision-Making

Chapter 17
17-2

Figure 17-1. The percentage of aviation accidents as they relate to the different phases of flight. Note that the greatest percentage of 

accidents take place during a minor percentage of the total flight.

Percentage of general aviation accidents

Flight Time

2%

Flight Time

83%

Flight Time

15%

Preflights/

Taxi

Takeoff/

Initial Climb Climb Cruise Descent Maneuvering Approach Landing Other

3.5% 3.3%

23.4%

15.7%

2.6%

13%

9.7%

24.1%

4.7%

Figure 16-1. The figure above illustrates the percentage of aviation accidents as they relate to the different phases of flight. 

Note that the greatest percentage of accidents take place during a minor percentage of the total flight; takeoff or landing phases.

The importance of learning and understanding effective 

ADM skills cannot be overemphasized. While progress is 

continually being made in the advancement of pilot training 

methods, aircraft equipment and systems, and services 

for pilots, accidents still occur. Despite all the changes in 

technology to improve flight safety, one factor remains the 

same: the human factor which leads to errors. It is estimated 

that approximately 80 percent of all aviation accidents are 

related to human factors and the vast majority of these 

accidents occur during landing (24.1 percent) and takeoff 

(23.4 percent). [Figure 17-1]

ADM is a systematic approach to risk assessment and stress 

management. To understand ADM is to also understand how 

personal attitudes can influence decision-making and how 

those attitudes can be modified to enhance safety in the flight 

deck. It is important to understand the factors that cause 

humans to make decisions and how the decision-making 

process not only works, but can be improved.

This chapter focuses on helping the pilot improve his or 

her ADM skills with the goal of mitigating the risk factors 

associated with flight. Advisory Circular (AC) 60-22, 

Aeronautical Decision-Making, provides background 

references, definitions, and other pertinent information about 

ADM training in the general aviation (GA) environment. 

[Figure 17-2] 

History of ADM

For over 25 years, the importance of good pilot judgment, or 

aeronautical decision-making (ADM), has been recognized 

as critical to the safe operation of aircraft, as well as accident 

avoidance. The airline industry, motivated by the need to 

reduce accidents caused by human factors, developed the first 

training programs based on improving ADM. Crew resource 

management (CRM) training for flight crews is focused on 

the effective use of all available resources: human resources, 

hardware, and information supporting ADM to facilitate crew 

cooperation and improve decision-making. The goal of all 

flight crews is good ADM and the use of CRM is one way 

to make good decisions.

Research in this area prompted the Federal Aviation 

Administration (FAA) to produce training directed at 

improving the decision-making of pilots and led to current 

FAA regulations that require that decision-making be taught 

as part of the pilot training curriculum. ADM research, 

development, and testing culminated in 1987 with the 

publication of six manuals oriented to the decision-making 

needs of variously rated pilots. These manuals provided 

multifaceted materials designed to reduce the number 

of decision related accidents. The effectiveness of these 

materials was validated in independent studies where student 

pilots received such training in conjunction with the standard 

flying curriculum. When tested, the pilots who had received 

ADM training made fewer inflight errors than those who had 
17-3

Figure 17-2. Advisory Circular (AC) 60-22, Aeronautical Decision Making, carries a wealth of information for the pilot to learn. Figure 16-2. The Advisory Circular, AC60-22 Aeronautical Decision Making carries a wealth of information that the pilot 

should be familiar not received ADM training. The differences were statistically 

significant and ranged from about 10 to 50 percent fewer 

judgment errors. In the operational environment, an operator 

flying about 400,000 hours annually demonstrated a 54 

percent reduction in accident rate after using these materials 

for recurrency training.

Contrary to popular opinion, good judgment can be taught. 

Tradition held that good judgment was a natural by-product 

of experience, but as pilots continued to log accident-free 

flight hours, a corresponding increase of good judgment 

was assumed. Building upon the foundation of conventional 

decision-making, ADM enhances the process to decrease 

the probability of human error and increase the probability 

of a safe flight. ADM provides a structured, systematic 

approach to analyzing changes that occur during a flight 

and how these changes might affect a flight’s safe outcome. 

The ADM process addresses all aspects of decision-making 

in the flight deck and identifies the steps involved in good 

decision-making.

Steps for good decision-making are: 

1. Identifying personal attitudes hazardous to safe 

flight.

2. Learning behavior modification techniques.

3. Learning how to recognize and cope with stress.

4. Developing risk assessment skills.

5. Using all resources.

6. Evaluating the effectiveness of one’s ADM skills.

Risk management is an important component of ADM. 

When a pilot follows good decision-making practices, the 

inherent risk in a flight is reduced or even eliminated. The 

ability to make good decisions is based upon direct or indirect 

experience and education. 

Consider automotive seat belt use. In just two decades, seat 

belt use has become the norm, placing those who do not 

wear seat belts outside the norm, but this group may learn 

to wear a seat belt by either direct or indirect experience. For 

example, a driver learns through direct experience about the 

value of wearing a seat belt when he or she is involved in a car 

accident that leads to a personal injury. An indirect learning 

experience occurs when a loved one is injured during a car 

accident because he or she failed to wear a seat belt. 

While poor decision-making in everyday life does not always 

lead to tragedy, the margin for error in aviation is thin. Since 

ADM enhances management of an aeronautical environment, 

all pilots should become familiar with and employ ADM.
17-4

Crew Resource Management (CRM) and 

Single-Pilot Resource Management

While CRM focuses on pilots operating in crew environments, 

many of the concepts apply to single-pilot operations. Many 

CRM principles have been successfully applied to single-pilot 

aircraft, and led to the development of Single-Pilot Resource 

Management (SRM). SRM is defined as the art and science 

of managing all the resources (both on-board the aircraft 

and from outside sources) available to a single pilot (prior 

and during flight) to ensure that the successful outcome 

of the flight. SRM includes the concepts of ADM, Risk 

Management (RM), Task Management (TM), Automation 

Management (AM), Controlled Flight Into Terrain (CFIT) 

Awareness, and Situational Awareness (SA). SRM training 

helps the pilot maintain situational awareness by managing 

the automation and associated aircraft control and navigation 

tasks. This enables the pilot to accurately assess and manage 

risk and make accurate and timely decisions. 

SRM is all about helping pilots learn how to gather 

information, analyze it, and make decisions. Although the 

flight is coordinated by a single person and not an onboard 

flight crew, the use of available resources such as air traffic 

control (ATC) and flight service station (FSS) replicates the 

principles of CRM. 

Hazard and Risk

Two defining elements of ADM are hazard and risk. Hazard 

is a real or perceived condition, event, or circumstance that a 

pilot encounters. When faced with a hazard, the pilot makes 

an assessment of that hazard based upon various factors. The 

pilot assigns a value to the potential impact of the hazard, 

which qualifies the pilot’s assessment of the hazard—risk.

Therefore, risk is an assessment of the single or cumulative 

hazard facing a pilot; however, different pilots see hazards 

differently. For example, the pilot arrives to preflight and 

discovers a small, blunt type nick in the leading edge at the 

middle of the aircraft’s prop. Since the aircraft is parked 

on the tarmac, the nick was probably caused by another 

aircraft’s prop wash blowing some type of debris into the 

propeller. The nick is the hazard (a present condition). The 

risk is prop fracture if the engine is operated with damage 

to a prop blade.

The seasoned pilot may see the nick as a low risk. He 

realizes this type of nick diffuses stress over a large area, is 

located in the strongest portion of the propeller, and based on 

experience, he doesn’t expect it to propagate a crack which 

can lead to high risk problems. He does not cancel his flight. 

The inexperienced pilot may see the nick as a high risk factor 

because he is unsure of the affect the nick will have on the 

prop’s operation and he has been told that damage to a prop 

could cause a catastrophic failure. This assessment leads him 

to cancel his flight. 

Therefore, elements or factors affecting individuals are 

different and profoundly impact decision-making. These 

are called human factors and can transcend education, 

experience, health, physiological aspects, etc.

Another example of risk assessment was the flight of a 

Beechcraft King Air equipped with deicing and anti-icing. 

The pilot deliberately flew into moderate to severe icing 

conditions while ducking under cloud cover. A prudent pilot 

would assess the risk as high and beyond the capabilities of 

the aircraft, yet this pilot did the opposite. Why did the pilot 

take this action? 

Past experience prompted the action. The pilot had 

successfully flown into these conditions repeatedly although 

the icing conditions were previously forecast 2,000 feet 

above the surface. This time, the conditions were forecast 

from the surface. Since the pilot was in a hurry and failed 

to factor in the difference between the forecast altitudes, 

he assigned a low risk to the hazard and took a chance. He 

and the passengers died from a poor risk assessment of the 

situation.

Hazardous Attitudes and Antidotes

Being fit to fly depends on more than just a pilot’s physical 

condition and recent experience. For example, attitude will 

affect the quality of decisions. Attitude is a motivational 

predisposition to respond to people, situations, or events in a 

given manner. Studies have identified five hazardous attitudes 

that can interfere with the ability to make sound decisions 

and exercise authority properly: anti-authority, impulsivity, 

invulnerability, macho, and resignation. [Figure 17-3]

Hazardous attitudes contribute to poor pilot judgment but 

can be effectively counteracted by redirecting the hazardous 

attitude so that correct action can be taken. Recognition of 

hazardous thoughts is the first step toward neutralizing them. 

After recognizing a thought as hazardous, the pilot should 

label it as hazardous, then state the corresponding antidote.

Antidotes should be memorized for each of the hazardous 

attitudes so they automatically come to mind when needed. 

Risk

During each flight, the single pilot makes many decisions 

under hazardous conditions. To fly safely, the pilot needs to 

assess the degree of risk and determine the best course of 

action to mitigate risk. 
17-5

Figure 17-4. This risk matrix can be used for almost any operation 

by assigning likelihood and consequence. In the case presented, 

the pilot assigned a likelihood of occassional and the severity as 

catastrophic. As one can see, this falls in the high risk area.

Catastrophic Critical Marginal Negligible

Improbable

Remote

Occasional

Probable

Risk Assessment Matrix

 Likelihood

Severity

Serious Medium Low

Serious

High High Serious

High

Figure 17-3. The five hazardous attitudes identified through past and contemporary study.

The Five Hazardous Attitudes

Anti-Authority: “Don’t tell me.”

This attitude is found in people who do not like anyone telling them what to do. In a sense, they are saying, “No one can tell me 

what to do.” They may be resentful of having someone tell them what to do, or may regard rules, regulations, and procedures as 

silly or unnecessary. However, it is always your prerogative to question authority if you feel it is in error.

Impulsivity: “Do it quickly.”

This is the attitude of people who frequently feel the need to do something, anything, immediately. They do not stop to think about 

what they are about to do; they do not select the best alternative, and they do the first thing that comes to mind.

Invulnerability: “It won’t happen to me.”

Many people falsely believe that accidents happen to others, but never to them. They know accidents can happen, and they know 

that anyone can be affected. However, they never really feel or believe that they will be personally involved. Pilots who think this way

are more likely to take chances and increase risk.

Macho: “I can do it.”

Pilots who are always trying to prove that they are better than anyone else think, “I can do it—I'll show them.” Pilots with this 

type of attitude will try to prove themselves by taking risks in order to impress others. While this pattern is thought to be a male 

characteristic, women are equally susceptible.

Resignation: “What’s the use?”

Pilots who think, “What’s the use?” do not see themselves as being able to make a great deal of difference in what happens to them. 

When things go well, the pilot is apt to think that it is good luck. When things go badly, the pilot may feel that someone is out to get 

me, or attribute it to bad luck. The pilot will leave the action to others, for better or worse. Sometimes, such pilots will even go along 

with unreasonable requests just to be a "nice guy."

Assessing Risk

For the single pilot, assessing risk is not as simple as it sounds. 

For example, the pilot acts as his or her own quality control 

in making decisions. If a fatigued pilot who has flown 16 

hours is asked if he or she is too tired to continue flying, the 

answer may be no. Most pilots are goal oriented and when 

asked to accept a flight, there is a tendency to deny personal 

limitations while adding weight to issues not germane to the 

mission. For example, pilots of helicopter emergency services 

(EMS) have been known (more than other groups) to make 

flight decisions that add significant weight to the patient’s 

welfare. These pilots add weight to intangible factors (the 

patient in this case) and fail to appropriately quantify actual 

hazards such as fatigue or weather when making flight 

decisions. The single pilot who has no other crew member 

for consultation must wrestle with the intangible factors that 

draw one into a hazardous position. Therefore, he or she has 

a greater vulnerability than a full crew. 

Examining National Transportation Safety Board (NTSB) 

reports and other accident research can help a pilot learn to 

assess risk more effectively. For example, the accident rate 

during night VFR decreases by nearly 50 percent once a 

pilot obtains 100 hours, and continues to decrease until the 

1,000 hour level. The data suggest that for the first 500 hours, 

pilots flying VFR at night might want to establish higher 

personal limitations than are required by the regulations 

and, if applicable, apply instrument flying skills in this 

environment. 

Several risk assessment models are available to assist in the 

process of assessing risk. The models, all taking slightly 

different approaches, seek a common goal of assessing risk 

in an objective manner. Two are illustrated below.

The most basic tool is the risk matrix. [Figure 17-4] It 

assesses two items: the likelihood of an event occurring and 

the consequence of that event. 
17-6

Likelihood of an Event

Likelihood is nothing more than taking a situation and 

determining the probability of its occurrence. It is rated as 

probable, occasional, remote, or improbable. For example, a 

pilot is flying from point A to point B (50 miles) in marginal 

visual flight rules (MVFR) conditions. The likelihood of 

encountering potential instrument meteorological conditions 

(IMC) is the first question the pilot needs to answer. The 

experiences of other pilots coupled with the forecast, might 

cause the pilot to assign “occasional” to determine the 

probability of encountering IMC. 

The following are guidelines for making assignments.

• Probable—an event will occur several times.

• Occasional—an event will probably occur 

sometime.

• Remote—an event is unlikely to occur, but is 

possible.

• Improbable—an event is highly unlikely to occur. 

Severity of an Event

The next element is the severity or consequence of a 

pilot’s action(s). It can relate to injury and/or damage. If 

the individual in the example above is not an instrument 

flight rules (IFR) pilot, what are the consequences of him 

or her encountering inadvertent IMC conditions? In this 

case, because the pilot is not IFR rated, the consequences 

are catastrophic. The following are guidelines for this 

assignment.

• Catastrophic—results in fatalities, total loss

• Critical—severe injury, major damage

• Marginal—minor injury, minor damage

• Negligible—less than minor injury, less than minor 

system damage

Simply connecting the two factors as shown in Figure 17-4

indicates the risk is high and the pilot must either not fly, or 

fly only after finding ways to mitigate, eliminate, or control 

the risk.

Although the matrix in Figure 17-4 provides a general 

viewpoint of a generic situation, a more comprehensive 

program can be made that is tailored to a pilot’s flying. 

[Figure 17-5] This program includes a wide array of aviation 

related activities specific to the pilot and assesses health, 

fatigue, weather, capabilities, etc. The scores are added and 

the overall score falls into various ranges, with the range 

representative of actions that a pilot imposes upon himself 

or herself. 

Mitigating Risk

Risk assessment is only part of the equation. After determining 

the level of risk, the pilot needs to mitigate the risk. For 

example, the pilot flying from point A to point B (50 miles) 

in MVFR conditions has several ways to reduce risk:

• Wait for the weather to improve to good visual flight 

rules (VFR) conditions.

• Take a pilot who is certified as an IFR pilot. 

• Delay the flight. 

• Cancel the flight.

• Drive.

One of the best ways to single pilots can mitigate risk is to 

use the IMSAFE checklist to determine physical and mental 

readiness for flying: 

1. Illness—Am I sick? Illness is an obvious pilot risk.

2. Medication—Am I taking any medicines that might 

affect my judgment or make me drowsy?

3. Stress—Am I under psychological pressure from the 

job? Do I have money, health, or family problems? 

Stress causes concentration and performance 

problems. While the regulations list medical conditions 

that require grounding, stress is not among them. 

The pilot should consider the effects of stress on 

performance. 

4. Alcohol—Have I been drinking within 8 hours? 

Within 24 hours? As little as one ounce of liquor, one 

bottle of beer, or four ounces of wine can impair flying 

skills. Alcohol also renders a pilot more susceptible 

to disorientation and hypoxia. 

5. Fatigue—Am I tired and not adequately rested? 

Fatigue continues to be one of the most insidious 

hazards to flight safety, as it may not be apparent to 

a pilot until serious errors are made. 

6. Eating—Have I eaten enough of the proper foods to 

keep adequately nourished during the entire flight?

The PAVE Checklist 

Another way to mitigate risk is to perceive hazards. By 

incorporating the PAVE checklist into preflight planning, 

the pilot divides the risks of flight into four categories: Pilotin-command (PIC), Aircraft, enVironment, and External 

pressures (PAVE) which form part of a pilot’s decisionmaking process.
17-7

RISK ASSESSMENT

Column total

Column total

SLEEP

1. Did not sleep well or less than 8 hours

2. Slept well

2

0

HOW DO YOU FEEL?

1. Have a cold or ill

2. Feel great

3. Feel a bit off

4

0

2

WEATHER AT TERMINATION

1. Greater than 5 miles visibility and 3,000 feet 

ceilings

2. At least 3 miles visibility and 1,000 feet ceilings,

 but less than 3,000 feet ceilings and 5 miles 

visibility 

3. IMC conditions

1

3

4

HOW IS THE DAY GOING?

1. Seems like one thing after another (late, 

 making errors, out of step)

2. Great day

3

0

IS THE FLIGHT

1. Day?

2. Night?

1

3

PLANNING

1. Rush to get off ground

2. No hurry

3. Used charts and computer to assist

4. Used computer program for all planning Yes

 No

5. Did you verify weight and balance? Yes 

 No

6. Did you evaluate performance? Yes

 No

7. Do you brief your passangers on the Yes

 ground and in flight? No

3

1

0

3

0

0

3

0

3

0

2

Pilot’s Name Flight From To

TOTAL SCORE

0 Not Complex Flight 10 Exercise Caution 20 Area of Concern 30

Endangerment

Low Ris

k

 Figure 17-5. Example of a more comprehensive risk assessment program.
17-8

With the PAVE checklist, pilots have a simple way to 

remember each category to examine for risk prior to each 

flight. Once a pilot identifies the risks of a flight, he or she 

needs to decide whether the risk or combination of risks can 

be managed safely and successfully. If not, make the decision 

to cancel the flight. If the pilot decides to continue with the 

flight, he or she should develop strategies to mitigate the 

risks. One way a pilot can control the risks is to set personal 

minimums for items in each risk category. These are limits 

unique to that individual pilot’s current level of experience 

and proficiency. 

For example, the aircraft may have a maximum crosswind 

component of 15 knots listed in the aircraft flight manual 

(AFM), and the pilot has experience with 10 knots of direct 

crosswind. It could be unsafe to exceed a 10 knots crosswind 

component without additional training. Therefore, the 10 kts 

crosswind experience level is that pilot’s personal limitation 

until additional training with a certificated flight instructor 

(CFI) provides the pilot with additional experience for flying 

in crosswinds that exceed 10 knots. 

One of the most important concepts that safe pilots 

understand is the difference between what is “legal” in terms 

of the regulations, and what is “smart” or “safe” in terms of 

pilot experience and proficiency.

P = Pilot in Command (PIC) 

The pilot is one of the risk factors in a flight. The pilot 

must ask, “Am I ready for this trip?” in terms of experience, 

recency, currency, physical and emotional condition. The 

IMSAFE checklist provides the answers.

A = Aircraft 

What limitations will the aircraft impose upon the trip? Ask 

the following questions:

• Is this the right aircraft for the flight?

• Am I familiar with and current in this aircraft? Aircraft 

performance figures and the AFM are based on a brand 

new aircraft flown by a professional test pilot. Keep 

that in mind while assessing personal and aircraft 

performance.

• Is this aircraft equipped for the flight? Instruments? 

Lights? Navigation and communication equipment 

adequate?

• Can this aircraft use the runways available for the trip 

with an adequate margin of safety under the conditions 

to be flown?

• Can this aircraft carry the planned load?

• Can this aircraft operate at the altitudes needed for the 

trip?

• Does this aircraft have sufficient fuel capacity, with 

reserves, for trip legs planned? 

• Does the fuel quantity delivered match the fuel 

quantity ordered?

V = EnVironment

Weather

Weather is an major environmental consideration. Earlier 

it was suggested pilots set their own personal minimums, 

especially when it comes to weather. As pilots evaluate 

the weather for a particular flight, they should consider the 

following:

• What are the current ceiling and visibility? In 

mountainous terrain, consider having higher minimums 

for ceiling and visibility, particularly if the terrain is 

unfamiliar.

• Consider the possibility that the weather may be 

different than forecast. Have alternative plans and 

be ready and willing to divert, should an unexpected 

change occur.

• Consider the winds at the airports being used and the 

strength of the crosswind component.

• If flying in mountainous terrain, consider whether there 

are strong winds aloft. Strong winds in mountainous 

terrain can cause severe turbulence and downdrafts 

and be very hazardous for aircraft even when there is 

no other significant weather.

• Are there any thunderstorms present or forecast?

• If there are clouds, is there any icing, current or 

forecast? What is the temperature/dew point spread 

and the current temperature at altitude? Can descent 

be made safely all along the route? 

• If icing conditions are encountered, is the pilot 

experienced at operating the aircraft’s deicing or 

anti-icing equipment? Is this equipment in good 

condition and functional? For what icing conditions 

is the aircraft rated, if any?

Terrain

Evaluation of terrain is another important component of 

analyzing the flight environment.

• To avoid terrain and obstacles, especially at night or 

in low visibility, determine safe altitudes in advance 

by using the altitudes shown on VFR and IFR charts 

during preflight planning.

• Use maximum elevation figures (MEFs) and other 

easily obtainable data to minimize chances of an 

inflight collision with terrain or obstacles. 
17-9

• The desire to impress someone. (Probably the two 

most dangerous words in aviation are “Watch this!”)

• The desire to satisfy a specific personal goal (“gethome-itis,” “get-there-itis,” and “let’s-go-itis”).

• The pilot’s general goal-completion orientation.

• Emotional pressure associated with acknowledging 

that skill and experience levels may be lower than a 

pilot would like them to be. Pride can be a powerful 

external factor! 

Managing External Pressures

Management of external pressure is the single most important 

key to risk management because it is the one risk factor 

category that can cause a pilot to ignore all the other risk 

factors. External pressures put time-related pressure on the 

pilot and figure into a majority of accidents.

The use of personal standard operating procedures (SOPs) is 

one way to manage external pressures. The goal is to supply a 

release for the external pressures of a flight. These procedures 

include but are not limited to:

• Allow time on a trip for an extra fuel stop or to make 

an unexpected landing because of weather.

• Have alternate plans for a late arrival or make backup 

airline reservations for must-be-there trips.

• For really important trips, plan to leave early enough 

so that there would still be time to drive to the 

destination.

• Advise those who are waiting at the destination that 

the arrival may be delayed. Know how to notify them 

when delays are encountered. 

• Manage passengers’ expectations. Make sure 

passengers know that they might not arrive on a firm 

schedule, and if they must arrive by a certain time, 

they should make alternative plans.

• Eliminate pressure to return home, even on a casual 

day flight, by carrying a small overnight kit containing 

prescriptions, contact lens solutions, toiletries, or other 

necessities on every flight.

The key to managing external pressure is to be ready for 

and accept delays. Remember that people get delayed when 

traveling on airlines, driving a car, or taking a bus. The pilot’s 

goal is to manage risk, not create hazards. [Figure 17-6]

Airport

• What lights are available at the destination and 

alternate airports? VASI/PAPI or ILS glideslope 

guidance? Is the terminal airport equipped with them? 

Are they working? Will the pilot need to use the radio 

to activate the airport lights?

• Check the Notices to Airmen (NOTAMS) for closed 

runways or airports. Look for runway or beacon lights 

out, nearby towers, etc.

• Choose the flight route wisely. An engine failure gives 

the nearby airports supreme importance. 

• Are there shorter or obstructed fields at the destination 

amd/or alternate airports?

Airspace

• If the trip is over remote areas, are appropriate 

clothing, water, and survival gear onboard in the event 

of a forced landing?

• If the trip includes flying over water or unpopulated 

areas with the chance of losing visual reference to the 

horizon, the pilot must be prepared to fly IFR.

• Check the airspace and any temporary flight restriction 

(TFRs) along the route of flight.

Nighttime

Night flying requires special consideration.

• If the trip includes flying at night over water or 

unpopulated areas with the chance of losing visual 

reference to the horizon, the pilot must be prepared 

to fly IFR.

• Will the flight conditions allow a safe emergency 

landing at night?

• Preflight all aircraft lights, interior and exterior, for 

a night flight. Carry at least two flashlights—one for 

exterior preflight and a smaller one that can be dimmed 

and kept nearby.

E = External Pressures

External pressures are influences external to the flight that 

create a sense of pressure to complete a flight—often at the 

expense of safety. Factors that can be external pressures 

include the following:

• Someone waiting at the airport for the flight’s 

arrival.

• A passenger the pilot does not want to disappoint.

• The desire to demonstrate pilot qualifications.
17-10

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 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 later convinced by the pilot that the risks involved were 

unacceptable.

Pilot

This encompasses many elements not pilot or airplane related. 

It can include such factors as weather, air traffic control, 

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

Aircraft

A pilot will frequently base decisions on the evaluations 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.

External Pressures

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 is it to 

maintain the schedule, and is the trip worth the risks?

On a ferry flight to deliver an airplane from the factory, in 

marginal weather conditions, the pilot calculated the 

groundspeed and determined that the airplane would arrive at 

the destination with only 10 minutes of fuel remaining. The pilot 

was determined to keep on schedule by trying to “stretch” the 

fuel supply instead of landing to refuel. After landing with low 

fuel state, the pilot realized that this could have easily resulted 

in an emergency landing in deteriorating weather conditions. 

This was a chance that was not worth taking to keep the 

planned schedule.

Figure 17-6. The PAVE checklist.

Human Behavior

Studies of human behavior have tried to determine an 

individual’s predisposition to taking risks and the level of 

an individual’s involvement in accidents. In 1951, a study 

regarding injury-prone children was published by Elizabeth 

Mechem Fuller and Helen B. Baune, of the University of 

Minnesota. The study was comprised of two separate groups 

of second grade students. Fifty-five students were considered 

accident repeaters and 48 students had no accidents. Both 

groups were from the same school of 600 and their family 

demographics were similar. 

The accident-free group showed a superior knowledge 

of safety, were considered industrious and cooperative 

with others, but were not considered physically inclined. 

The accident-repeater group had better gymnastic skills, 

were considered aggressive and impulsive, demonstrated 

rebellious behavior when under stress, were poor losers, and 

liked to be the center of attention. One interpretation of this 

data—an adult predisposition to injury stems from childhood 

behavior and environment—leads to the conclusion that 

any pilot group should be comprised only of pilots who are 

safety-conscious, industrious, and cooperative. 

Clearly, this is not only an inaccurate inference, it is 

impossible. Pilots are drawn from the general population and 

exhibit all types of personality traits. Thus, it is important that 

good decision-making skills be taught to all pilots.

Historically, the term “pilot error” has been used to describe 

an accident in which an action or decision made by the 

pilot was the cause or a contributing factor that led to the 

accident. This definition also includes the pilot’s failure 

to make a correct decision or take proper action. From a 

broader perspective, the phrase “human factors related” more 

aptly describes these accidents. A single decision or event 

does not lead to an accident, but a series of events and the 

resultant decisions together form a chain of events leading 

to an outcome.

In his article “Accident-Prone Pilots,” Dr. Patrick R. Veillette 

uses the history of “Captain Everyman” to demonstrate how 

aircraft accidents are caused more by a chain of poor choices 

rather than one single poor choice. In the case of Captain 

Everyman, after a gear-up landing accident, he became 

involved in another accident while taxiing a Beech 58P 

Baron out of the ramp. Interrupted by a radio call from the 
17-11

dispatcher, Everyman neglected to complete the fuel crossfeed check before taking off. Everyman, who was flying 

solo, left the right-fuel selector in the cross-feed position. 

Once aloft and cruising, he noticed a right roll tendency 

and corrected with aileron trim. He did not realize that both 

engines were feeding off the left wing’s tank, making the 

wing lighter.

After two hours of flight, the right engine quit when 

Everyman was flying along a deep canyon gorge. While he 

was trying to troubleshoot the cause of the right engine’s 

failure, the left engine quit. Everyman landed the aircraft on 

a river sand bar but it sank into ten feet of water.

Several years later Everyman flew a de Havilland Twin Otter 

to deliver supplies to a remote location. When he returned to 

home base and landed, the aircraft veered sharply to the left, 

departed the runway, and ran into a marsh 375 feet from the 

runway. The airframe and engines sustained considerable 

damage. Upon inspecting the wreck, accident investigators 

found the nose wheel steering tiller in the fully deflected 

position. Both the after takeoff and before landing checklists 

required the tiller to be placed in the neutral position. 

Everyman had overlooked this item. 

Now, is Everyman accident prone or just unlucky? Skipping 

details on a checklist appears to be a common theme in the 

preceding accidents. While most pilots have made similar 

mistakes, these errors were probably caught prior to a mishap 

due to extra margin, good warning systems, a sharp copilot, or 

just good luck. What makes a pilot less prone to accidents?

The successful pilot possesses the ability to concentrate, 

manage workloads, monitor and perform several simultaneous 

tasks. Some of the latest psychological screenings used 

in aviation test applicants for their ability to multitask, 

measuring both accuracy, as well as the individual’s ability 

to focus attention on several subjects simultaneously. The 

FAA oversaw an extensive research study on the similarities 

and dissimilarities of accident-free pilots and those who were 

not. The project surveyed over 4,000 pilots, half of whom 

had “clean” records while the other half had been involved 

in an accident. 

Five traits were discovered in pilots prone to having 

accidents. These pilots: 

• Have disdain toward rules. 

• Have very high correlation between accidents on their 

flying records and safety violations on their driving 

records.

• Frequently fall into the “thrill and adventure seeking” 

personality category.

• Are impulsive rather than methodical and disciplined, 

both in their information gathering and in the speed 

and selection of actions to be taken.

• A disregard for or under utilization of outside sources 

of information, including copilots, flight attendants, 

flight service personnel, flight instructors, and air 

traffic controllers.

The Decision-Making Process

An understanding of the decision-making process provides 

the pilot with a foundation for developing ADM and SRM 

skills. While some situations, such as engine failure, require 

an immediate pilot response using established procedures, 

there is usually time during a flight to analyze any changes 

that occur, gather information, and assess risk before reaching 

a decision. 

Risk management and risk intervention is much more than 

the simple definitions of the terms might suggest. Risk 

management and risk intervention are decision-making 

processes designed to systematically identify hazards, 

assess the degree of risk, and determine the best course of 

action. These processes involve the identification of hazards, 

followed by assessments of the risks, analysis of the controls, 

making control decisions, using the controls, and monitoring 

the results. 

The steps leading to this decision constitute a decisionmaking process. Three models of a structured framework 

for problem-solving and decision-making are the 5-P, the 3P, 

the 3 with CARE and TEAM, the OODA, and the DECIDE 

models. They provide assistance in organizing the decision 

process. All these models have been identified as helpful to 

the single pilot in organizing critical decisions. 

SRM and the 5P Check 

SRM is about how to gather information, analyze it, and make 

decisions. Learning how to identify problems, analyze the 

information, and make informed and timely decisions is not 

as straightforward as the training involved in learning specific 

maneuvers. Learning how to judge a situation and “how to 

think” in the endless variety of situations encountered while 

flying out in the “real world” is more difficult.

There is no one right answer in ADM, rather each pilot is 

expected to analyze each situation in light of experience 

level, personal minimums, and current physical and mental 

readiness level, and make his or her own decision. 

SRM sounds good on paper, but it requires a way for pilots 

to understand and use it in their daily flights. One practical 

application is called the “Five Ps (5 Ps)” [Figure 17-7] The 
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Figure 17-7. The Five P checklist.

The SRM Five “P” Check

The Plan

The Plane

The Pilot

The Passengers

The Programming

Figure 16-15. Illustrates the use of The Five-P checklist, which

has significant application to those using onboard management

systems. 5 Ps consist of “the Plan, the Plane, the Pilot, the Passengers, 

and the Programming.” Each of these areas consists of a set of 

challenges and opportunities that face a single pilot. And each 

can substantially increase or decrease the risk of successfully 

completing the flight based on the pilot’s ability to make 

informed and timely decisions. The 5 Ps are used to evaluate 

the pilot’s current situation at key decision points during the 

flight, or when an emergency arises. These decision points 

include, preflight, pretakeoff, hourly or at the midpoint of 

the flight, pre-descent, and just prior to the final approach 

fix or for visual flight rules (VFR) operations, just prior to 

entering the traffic pattern. 

The 5 Ps are based on the idea that the pilots have essentially 

five variables that impact his or her environment and that can 

cause the pilot to make a single critical decision, or several 

less critical decisions, that when added together can create 

a critical outcome. These variables are the Plan, the Plane, 

the Pilot, the Passengers, and the Programming. This concept 

stems from the belief that current decision-making models 

tended to be reactionary in nature. A change has to occur and 

be detected to drive a risk management decision by the pilot. 

For instance, many pilots use risk management sheets that are 

filled out by the pilot prior to takeoff. These form a catalog 

of risks that may be encountered that day and turn them into 

numerical values. If the total exceeds a certain level, the flight 

is altered or cancelled. Informal research shows that while 

these are useful documents for teaching risk factors, they are 

almost never used outside of formal training programs. The 

5P concept is an attempt to take the information contained in 

those sheets and in the other available models and use it. 

The 5P concept relies on the pilot to adopt a “scheduled” 

review of the critical variables at points in the flight where 

decisions are most likely to be effective. For instance, the 

easiest point to cancel a flight due to bad weather is before the 

pilot and passengers walk out the door and load the aircraft. 

So the first decision point is preflight in the flight planning 

room, where all the information is readily available to make 

a sound decision, and where communication and Fixed 

Base Operator (FBO) services are readily available to make 

alternate travel plans. 

The second easiest point in the flight to make a critical safety 

decision is just prior to takeoff. Few pilots have ever had to 

make an “emergency takeoff”. While the point of the 5P 

check is to help the pilot fly, the correct application of the 

5P before takeoff is to assist in making a reasoned go no-go 

decision based on all the information available. That decision 

will usually be to “go,” with certain restrictions and changes, 

but may also be a “no-go.” The key point is that these two 

points in the process of flying are critical go no-go points on 

each and every flight. 

The third place to review the 5 Ps is at the mid point of the 

flight. Often, pilots may wait until the Automated Terminal 

information Service (ATIS) is in range to check weather, yet 

at this point in the flight many good options have already 

passed behind the aircraft and pilot. Additionally, fatigue 

and low-altitude hypoxia serve to rob the pilot of much of 

his or her energy by the end of a long and tiring flight day. 

This leads to a transition from a decision-making mode to an 

acceptance mode on the part of the pilot. If the flight is longer 

than 2 hours, the 5P check should be conducted hourly. 

The last two decision points are just prior to descent into the 

terminal area and just prior to the final approach fix, or if 

VFR just prior to entering the traffic pattern, as preparations 

for landing commence. Most pilots execute approaches with 

the expectation that they will land out of the approach every 

time. A healthier approach requires the pilot to assume that 

changing conditions (the 5 Ps again) will cause the pilot to 

divert or execute the missed approach on every approach. 

This keeps the pilot alert to all manner of conditions that 

may increase risk and threaten the safe conduct of the flight. 

Diverting from cruise altitude saves fuel, allows unhurried 

use of the autopilot, and is less reactive in nature. Diverting 

from the final approach fix, while more difficult, still allows 

the pilot to plan and coordinate better, rather than executing 

a futile missed approach. Let’s look at a detailed discussion 

of each of the Five Ps.

The Plan 

The “Plan” can also be called the mission or the task. It 

contains the basic elements of cross-country planning, 

weather, route, fuel, publications currency, etc. The “Plan” 

should be reviewed and updated several times during the 

course of the flight. A delayed takeoff due to maintenance, 

fast moving weather, and a short notice TFR may all radically 

alter the plan. The “plan” is not only about the flight plan, 

but also all the events that surround the flight and allow the 

pilot to accomplish the mission. The plan is always being 

updated and modified and is especially responsive to changes 

in the other four remaining Ps. If for no other reason, the 5P 
17-13

check reminds the pilot that the day’s flight plan is real life 

and subject to change at any time. 

Obviously weather is a huge part of any plan. The addition 

of datalink weather information give the advanced avionics 

pilot a real advantage in inclement weather, but only if 

the pilot is trained to retrieve, and evaluate the weather in 

real time without sacrificing situational awareness. And of 

course, weather information should drive a decision, even 

if that decision is to continue on the current plan. Pilots of 

aircraft without datalink weather should get updated weather 

in flight through a Flight Service Station (FSS) and/or Flight 

Watch. 

The Plane 

Both the “plan” and the “plane” are fairly familiar to most 

pilots. The “plane” consists of the usual array of mechanical 

and cosmetic issues that every aircraft pilot, owner, or 

operator can identify. With the advent of advanced avionics, 

the “plane” has expanded to include database currency, 

automation status, and emergency backup systems that were 

unknown a few years ago. Much has been written about single 

pilot IFR flight both with and without an autopilot. While this 

is a personal decision, it is just that—a decision. Low IFR 

in a non-autopilot equipped aircraft may depend on several 

of the other Ps to be discussed. Pilot proficiency, currency, 

and fatigue are among them. 

The Pilot 

Flying, especially when used for business transportation, 

can expose the pilot to high altitude flying, long distance 

and endurance, and more challenging weather. An advanced 

avionics aircraft, simply due to their advanced capabilities can 

expose a pilot to even more of these stresses. The traditional 

“IMSAFE” checklist (see page 17-6) is a good start. 

The combination of late night, pilot fatigue, and the effects 

of sustained flight above 5,000 feet may cause pilots to 

become less discerning, less critical of information, less 

decisive and more compliant and accepting. Just as the most 

critical portion of the flight approaches (for instance a night 

instrument approach, in the weather, after a 4-hour flight) the 

pilot’s guard is down the most. The 5P process helps a pilot 

recognize the physiological situation at the end of the flight 

before takeoff, and continues to update personal conditions 

as the flight progresses. Once risks are identified, the pilot is 

in an infinitely better place to make alternate plans that lessen 

the effect of these factors and provide a safer solution. 

The Passengers 

One of the key differences between CRM and SRM is 

the way passengers interact with the pilot. The pilot of a 

highly capable single-engine aircraft has entered into a very 

personal relationship with the passengers. In fact, the pilot 

and passengers sit within an arm’s reach all of the time. 

The desire of the passengers to make airline connections or 

important business meetings easily enters into this pilot’s 

decision-making loop. Done in a healthy and open way, this 

can be a positive factor. Consider a flight to Dulles Airport 

and the passengers, both close friends and business partners, 

need to get to Washington, D.C., for an important meeting. 

The weather is VFR all the way to southern Virginia then turns 

to low IFR as the pilot approaches Dulles. A pilot employing 

the 5P approach might consider reserving a rental car at an 

airport in northern North Carolina or southern Virginia to 

coincide with a refueling stop. Thus, the passengers have a 

way to get to Washington, and the pilot has an out to avoid 

being pressured into continuing the flight if the conditions 

do not improve. 

Passengers can also be pilots. If no one is designated as pilot 

in command (PIC) and unplanned circumstances arise, the 

decision-making styles of several self-confident pilots may 

come into conflict. 

Pilots also need to understand that non-pilots may not 

understand the level of risk involved in the flight. There is 

an element of risk in every flight. That is why SRM calls it 

risk management, not risk elimination. While a pilot may feel 

comfortable with the risk present in a night IFR flight, the 

passengers may not. A pilot employing SRM should ensure 

the passengers are involved in the decision-making and given 

tasks and duties to keep them busy and involved. If, upon a 

factual description of the risks present, the passengers decide 

to buy an airline ticket or rent a car, then a good decision has 

generally been made. This discussion also allows the pilot 

to move past what he or she thinks the passengers want to 

do and find out what they actually want to do. This removes 

self-induced pressure from the pilot. 

The Programming 

The advanced avionics aircraft adds an entirely new 

dimension to the way GA aircraft are flown. The electronic 

instrument displays, GPS, and autopilot reduce pilot 

workload and increase pilot situational awareness. While 

programming and operation of these devices are fairly simple 

and straightforward, unlike the analog instruments they 

replace, they tend to capture the pilot’s attention and hold it 

for long periods of time. To avoid this phenomenon, the pilot 

should plan in advance when and where the programming 

for approaches, route changes, and airport information 

gathering should be accomplished as well as times it should 

not. Pilot familiarity with the equipment, the route, the local 
17-14

air traffic control environment, and personal capabilities visà-vis the automation should drive when, where, and how the 

automation is programmed and used. 

The pilot should also consider what his or her capabilities 

are in response to last minute changes of the approach (and 

the reprogramming required) and ability to make largescale changes (a reroute for instance) while hand flying the 

aircraft. Since formats are not standardized, simply moving 

from one manufacturer’s equipment to another should give 

the pilot pause and require more conservative planning and 

decisions. 

The SRM process is simple. At least five times before and 

during the flight, the pilot should review and consider the “Plan, 

the Plane, the Pilot, the Passengers, and the Programming” 

and make the appropriate decision required by the current 

situation. It is often said that failure to make a decision is a 

decision. Under SRM and the 5 Ps, even the decision to make 

no changes to the current plan, is made through a careful 

consideration of all the risk factors present.

Perceive, Process, Perform (3P)

The Perceive, Process, Perform (3P) model for ADM offers 

a simple, practical, and systematic approach that can be used 

during all phases of flight. To use it, the pilot will:

• Perceive the given set of circumstances for a flight.

• Process by evaluating their impact on flight safety.

• Perform by implementing the best course of action.

In the first step, the goal is to develop situational awareness 

by perceiving hazards, which are present events, objects, or 

circumstances that could contribute to an undesired future 

event. In this step, the pilot will systematically identify and 

list hazards associated with all aspects of the flight: pilot, 

aircraft, environment, and external pressures. It is important 

to consider how individual hazards might combine. Consider, 

for example, the hazard that arises when a new instrument 

pilot with no experience in actual instrument conditions wants 

to make a cross-country flight to an airport with low ceilings 

in order to attend an important business meeting.

In the second step, the goal is to process this information 

to determine whether the identified hazards constitute risk, 

which is defined as the future impact of a hazard that is not 

controlled or eliminated. The degree of risk posed by a given 

hazard can be measured in terms of exposure (number of 

people or resources affected), severity (extent of possible 

loss), and probability (the likelihood that a hazard will cause 

a loss). If the hazard is low ceilings, for example, the level 

of risk depends on a number of other factors, such as pilot 

training and experience, aircraft equipment and fuel capacity, 

and others.

In the third step, the goal is to perform by taking action to 

eliminate hazards or mitigate risk, and then continuously 

evaluate the outcome of this action. With the example of low 

ceilings at destination, for instance, the pilot can perform 

good ADM by selecting a suitable alternate, knowing where 

to find good weather, and carrying sufficient fuel to reach 

it. This course of action would mitigate the risk. The pilot 

also has the option to eliminate it entirely by waiting for 

better weather.

Once the pilot has completed the 3P decision process and 

selected a course of action, the process begins anew because 

now the set of circumstances brought about by the course of 

action requires analysis. The decision-making process is a 

continuous loop of perceiving, processing and performing.

With practice and consistent use, running through the 3P 

cycle can become a habit that is as smooth, continuous, and 

automatic as a well-honed instrument scan. This basic set of 

practical risk management tools can be used to improve risk 

management. The 3P model has been expanded to include the 

CARE and TEAM models which offers pilots another way 

to assess and reduce risks associated with flying. 

Perceive, Process, Perform with CARE and TEAM

Most flight training activities take place in the “time-critical” 

timeframe for risk management. Figures 17-8 and 17-9

combine the six steps of risk management into an easy-toremember 3P model for practical risk management: Perceive, 

Process, Perform with the CARE and TEAM models. Pilots 

can help perceive hazards by using the PAVE checklist 

of: Pilot, Aircraft, enVironment, and External pressures. 

They can process hazards by using the CARE checklist 

of: Consequences, Alternatives, Reality, External factors. 

Finally, pilots can perform risk management by using 

the TEAM choice list of: Transfer, Eliminate, Accept, or 

Mitigate. These concepts are relatively new in the GA training 

world, but have been shown to be extraordinarily useful in 

lowering accident rates in the world of air carriers. 
17-15

Figure 17-8. A real-world example of how the 3P model guides decisions on a cross-country trip.

Gayle is a healthy and well-rested private pilot with approximately 300 hours total flight time. Hazards include her lack of 

overall and cross-country experience and the fact that she has 

not flown at all in two months.

Pilot

Departure and destination airports have long runways.

Weather is the main hazard. Although it is VFR, it is a typical 

summer day in the Mid-Atlantic region: hot (near 90 °F) hazy 

(visibility 7 miles), and humid with a density altitude of 2,500 

feet. Weather at the destination airport (located in the 

mountains) is still IMC, but forecast to improve to visual 

meteorological conditions (VMC) prior to her arrival. En route 

weather is VMC, but there is an AIRMET Sierra for pockets of 

IMC over mountain ridges along the proposed route of flight.

EnVironment

Aircraft

Although it does not have a panel-mount GPS or weather

avoidance gear, the aircraft—a C182 Skylane with long-range

fuel tanks—is in good mechanical condition with no inoperative

equipment. The instrument panel is a standard “six-pack.”

External Pressures

Gayle is making the trip to spend a weekend with relatives she 

does not see very often. Her family is very excited and has 

made a number of plans for the visit.

Pilots can perceive hazards by using the PAVE checklist:

To manage the risk associated with her inexperience and lack 

of recent flight time, Gayle can:

• Transfer the risk entirely by having another pilot act as PIC.

• Eliminate the risk by canceling the trip.

• Accept the risk and fly anyway.

• Mitigate the risk by flying with another pilot.

Gayle chooses to mitigate the major risk by hiring a CFI to 

accompany her and provide dual cross-country instruction.

An added benefit is the opportunity to broaden her flying 

experience.

Pilot

To manage the risk associated with hazy conditions and 

mountainous terrain, Gayle can:

• Transfer the risk of VFR in these conditions by asking an 

instrument-rated pilot to fly the trip under IFR.

• Eliminate the risk by canceling the trip.

• Accept the risk.

• Mitigate the risk by careful preflight planning, filing a VFR 

flight plan, requesting VFR flight following, and using 

resources such as Flight Watch.

Detailed preflight planning must be a vital part of Gayle’s 

weather risk mitigation strategy. The most direct route would 

put her over mountains for most of the trip. Because of the 

thick haze and pockets of IMC over mountains, Gayle might 

mitigate the risk by modifying the route to fly over valleys. This 

change will add 30 minutes to her estimated time of arrival 

(ETA), but the extra time is a small price to pay for avoiding 

possible IMC over mountains. Because her destination airport 

is IMC at the time of departure, Gayle needs to establish that 

VFR conditions exist at other airports within easy driving 

distance of her original destination. In addition, Gayle should 

review basic information (e.g., traffic pattern altitude, runway

layout, frequencies) for these alternate airports. To further 

mitigate risk and practice good cockpit resource management, 

Gayle should file a VFR flight plan, use VFR flight following, 

and call Flight Watch to get weather updates en route. Finally, 

basic functions on her handheld GPS should also be practiced.

Environment

Aircraft

To manage risk associated with any doubts about the aircraft’s

mechanical condition, Gayle can: 

• Transfer the risk by using a different airplane.

• Eliminate the risk by canceling the trip.

• Accept the risk.

• Mitigate the remaining (residual) risk through review of 

 aircraft performance and careful preflight inspection.

Since she finds no problems with the aircraft’s mechanical

condition, Gayle chooses to mitigate any remaining risk 

through careful preflight inspection of the aircraft.

External Pressures

To mitigate the risk of emotional pressure from family

expectations that can drive a “get-there” mentality, Gayle can:

• Transfer the risk by having her co-pilot act as PIC and make 

the continue/divert decision.

• Eliminate the risk by canceling the trip.

• Accept the risk.

• Mitigate the risk by managing family expectations and 

 making alternative arrangements in the event of diversion to

 another airport.

Gayle and her co-pilot choose to address this risk by agreeing 

that each pilot has a veto on continuing the flight, and that they 

will divert if either becomes uncomfortable with flight conditions.

Because the destination airport is still IMC at the time of

departure, Gayle establishes a specific point in the trip—an en

route VORTAC located between the destination airport and the 

two alternates—as the logical place for her “final” continue/

divert decision. Rather than give her family a specific ETA that 

might make Gayle feel pressured to meet the schedule, she

manages her family’s expectations by advising them that she

will call when she arrives.

Pilots can perform risk management by using the TEAM choice list:
17-16

Figure 17-9. Additional real-world examples of how the 3P model guides decisions on a cross-country trip.

• Consequences: Gayle’s inexperience and lack of recent 

 flight time create some risk of an accident, primarily because 

she plans to travel over mountains on a hazy day and land 

 at an unfamiliar mountain airport that is still in IMC 

conditions. 

• Alternatives: Gayle might mitigate the pilot-related risk by 

 hiring a CFI to accompany her and provide dual crosscountry instruction. An added benefit is the opportunity to 

broaden her flying experience in safe conditions. 

• Reality: Accepting the reality that limited experience can 

 create additional risk is a key part of sound risk management 

 and mitigation. 

• External Factors: Like many pilots, Gayle must contend with 

 the emotional pressure associated with acknowledging that 

 her skill and experience levels may be lower than she would 

 like them to be. Pride can be a powerful external factor!

Pilot

• Consequences: For a pilot whose experience consists 

mostly of local flights in good VMC, launching a long crosscountry flight over mountainous terrain in hazy conditions 

could lead to pilot disorientation and increase the risk of an 

accident. 

• Alternatives: Options include postponing the trip until the 

visibility improves, or modifying the route to avoid extended 

 periods of time over the mountains. 

• Reality: Hazy conditions and mountainous terrain clearly 

 create risk for an inexperienced VFR-only pilot. 

• External Factors: Few pilots are immune to the pressure of 

“get-there-itis,” which can sometimes induce a decision to 

 launch or continue in less than ideal weather conditions. 

Environment

Aircraft

• Consequences: This area presents low risk because the 

 aircraft is in excellent mechanical condition and Gayle is 

 familiar with its avionics.

• Alternatives: Had there been a problem with her aircraft, 

 Gayle might have considered renting another plane from her 

 flight school. Bear in mind, however, that alternatives 

sometimes create new hazards. In this instance, there may 

 be hazards associated with flying an unfamiliar aircraft with 

 different avionics. 

• Reality: It is important to recognize the reality of an aircraft’s 

mechanical condition. If you find a maintenance discrepancy 

 and then find yourself saying that it is “probably” okay to fly 

 with it anyway, you need to revisit the consequences part of 

 this checklist. 

• External Factors: Pilot decision-making can sometimes be 

 influenced by the external pressure of needing to return the 

 airplane to the FBO by a certain date and time. Because 

 Gayle owns the airplane, there was no such pressure in this 

case. 

External Pressures

• Consequences: Any number of factors can create risk of 

 emotional pressure from a “get-there” mentality. In Gayle’s 

 case, the consequences of her strong desire to visit family, 

 her family’s expectations, and personal pride could induce 

 her to accept unnecessary risk. 

• Alternatives: Gayle clearly needs to develop a mitigating 

 strategy for each of the external factors associated with this 

 trip. 

• Reality: Pilots sometimes tend to discount or ignore the 

 potential impact of these external factors. Gayle’s open 

 acknowledgement of these factors (e.g., “I might be 

 pressured into pressing on so my mother won’t have to 

 worry about our late arrival.”) is a critical element of effective 

 risk management. 

• External Factors: (see above) 

Pilots can perceive hazards by using the CARE checklist:

Forming Good Safety Habits 

While the 3P model is similar to other methods, there are 

two good reasons to use the 3P model. First, the 3P model 

gives pilots a structured, efficient, and systematic way to 

identify hazards, assess risk, and implement effective risk 

controls. Second, practicing risk management needs to be as 

automatic in GA flying as basic aircraft control. As is true 

for other flying skills, risk management thinking habits are 

best developed through repetition and consistent adherence 

to specific procedures.

The OODA Loop

Colonel John Boyd, United States Air Forces (Retired), 

coined the term and developed the concept of the “OODA 

Loop” (Observation, Orientation, Decision, Action). The 

ideas, words, and phrases contained in Boyd’s briefings have 

penetrated not only the United States military services, but the 

business community and worldwide academia. The OODA 

Loop is now used as a standard description of decisionmaking cycles.

The Loop is an interlaced decision model which provides 

immediate feedback throughout the decision-making process. 

For SRM purposes, an abbreviated version of the concept 

[Figure 17-10] provides an easily understood tool for the 

pilot.

The first node of the Loop, Observe, reflects the need for 

situational awareness. A pilot must be aware of those things 

around him or her that may impact the flight. Continuous 

monitoring of aircraft controls, weather, etc., provides a 

constant reference point by which the pilot knows his or 

her starting point on the loop which permits the ability to 

immediately move to the next step.
17-17

Figure 17-10. The OODA Loop.

Figure 1-8. The Observation, Orientation, Decision, Action (OODA Loop).

ACT

OBSERVE

ORIENT

DECIDE

Orient, the second node of the Loop, focuses the pilot’s 

attention on one or more discrepancies in the flight. For 

example, there is a low oil pressure reading. The pilot is 

aware of this deviation and considers available options in 

view of potential hazards to continued flight.

The pilot then moves to the third node, Decide, in which 

he or she makes a positive determination about a specific 

effect. That decision is made based on experience and 

knowledge of potential results, and to take that particular 

action will produce the desired result. The pilot then Acts on 

that decision, making a physical input to cause the aircraft 

to react in the desired fashion.

Once the loop has been completed, the pilot is once again in 

the Observe position. The assessment of the resulting action 

is added to the previously perceived aspects of the flight to 

further define the flight’s progress. The advantage of the 

OODA Loop model is that it may be cumulative, as well as 

having the potential of allowing for multiple progressions to 

occur at any given point in the flight.

The DECIDE Model

Using the acronym “DECIDE,” the six-step process DECIDE 

Model is another continuous loop process that provides the 

pilot with a logical way of making decisions. [Figure 17-11]

DECIDE means to Detect, Estimate, Choose a course of 

action, Identify solutions, Do the necessary actions, and 

Evaluate the effects of the actions. 

First, consider a recent accident involving a Piper Apache (PA23). The aircraft was substantially damaged during impact 

with terrain at a local airport in Alabama. The certificated 

airline transport pilot (ATP) received minor injuries and the 

certificated private pilot was not injured. The private pilot 

was receiving a checkride from the ATP (who was also a 

designated examiner) for a commercial pilot certificate with 

a multi-engine rating. After performing airwork at altitude, 

they returned to the airport and the private pilot performed a 

single-engine approach to a full stop landing. He then taxied 

back for takeoff, performed a short field takeoff, and then 

joined the traffic pattern to return for another landing. During 

the approach for the second landing, the ATP simulated a right 

engine failure by reducing power on the right engine to zero 

thrust. This caused the aircraft to yaw right. 

The procedure to identify the failed engine is a two-step 

process. First, bring power to maximum controllable on both 

engines. Because the left engine is the only engine delivering 

thrust, the yaw increases to the right, which necessitates 

application of additional left rudder application. The failed 

engine is the side that requires no rudder pressure, in this 

case the right engine. Second, having identified the failed 

right engine, the procedure is to feather the right engine and 

adjust power to maintain descent angle to a landing.

However, in this case the pilot feathered the left engine 

because he assumed the engine failure was a left engine 

failure. During twin-engine training, the left engine out 

is emphasized more than the right engine because the left 

engine on most light twins is the critical engine. This is due to 

multiengine airplanes being subject to P-factor, as are singleengine airplanes. The descending propeller blade of each 

engine will produce greater thrust than the ascending blade 

when the airplane is operated under power and at positive 

angles of attack. The descending propeller blade of the right 

engine is also a greater distance from the center of gravity, 

and therefore has a longer moment arm than the descending 

propeller blade of the left engine. As a result, failure of the left 

engine will result in the most asymmetrical thrust (adverse 

yaw) because the right engine will be providing the remaining 

thrust. Many twins are designed with a counter-rotating right 

engine. With this design, the degree of asymmetrical thrust 

is the same with either engine inoperative. Neither engine is 

more critical than the other.
17-18

1.

2.

3.

4

5.

6.

The DECIDE Model

Aeronautical Decision-Making

A. Analytical B. Automatic/Naturalistic

Evaluation of event

Outcome desired

What is best action to do

Effect of decision

Detection

Situation

Pilot Aircraft Enviroment External Factors

• Risk or hazard

• Potential outcomes

• Capabilities of pilot

• Aircraft capabilities

• Outside factors

Solutions to get you there

Solution 1

Solution 2

Solution 3

Solution 4

Problem remains

Done

Evaluation of event

Outcome desired

Take action

Detection

Pilot Aircraft Enviroment External Factors

• Risk to flight

• Pilot training

• Pilot experience

Successful

Figure 17-11. The DECIDE model has been recognized worldwide. Its application is illustrated in A while automatic/naturalistic 

decision-making is shown in B.
17-19

Since the pilot never executed the first step of identifying 

which engine failed, he feathered the left engine and set the 

right engine at zero thrust. This essentially restricted the 

aircraft to a controlled glide. Upon realizing that he was not 

going to make the runway, the pilot increased power to both 

engines causing an enormous yaw to the left (the left propeller 

was feathered) whereupon the aircraft started to turn left. 

In desperation, the instructor closed both throttles and the 

aircraft hit the ground and was substantially damaged. 

This case is interesting because it highlights two particular 

issues. First, taking action without forethought can be just 

as dangerous as taking no action at all. In this case, the 

pilot’s actions were incorrect; yet, there was sufficient 

time to take the necessary steps to analyze the simulated 

emergency. The second and more subtle issue is that decisions 

made under pressure are sometimes executed based upon 

limited experience and the actions taken may be incorrect, 

incomplete, or insufficient to handle the situation. 

Detect (the Problem)

Problem detection is the first step in the decision-making 

process. It begins with recognizing a change occurred or an 

expected change did not occur. A problem is perceived first 

by the senses and then it is distinguished through insight 

and experience. These same abilities, as well as an objective 

analysis of all available information, are used to determine the 

nature and severity of the problem. One critical error made 

during the decision-making process is incorrectly detecting 

the problem. In the example above, the change that occurred 

was a yaw. 

Estimate (the Need To React)

In the engine-out example, the aircraft yawed right, the pilot 

was on final approach, and the problem warranted a prompt 

solution. In many cases, overreaction and fixation excludes 

a safe outcome. For example, what if the cabin door of a 

Mooney suddenly opened in flight while the aircraft climbed 

through 1,500 feet on a clear sunny day? The sudden opening 

would be alarming, but the perceived hazard the open door 

presents is quickly and effectively assessed as minor. In 

fact, the door’s opening would not impact safe flight and 

can almost be disregarded. Most likely, a pilot would return 

to the airport to secure the door after landing. 

The pilot flying on a clear day faced with this minor problem 

may rank the open cabin door as a low risk. What about 

the pilot on an IFR climb out in IMC conditions with light 

intermittent turbulence in rain who is receiving an amended 

clearance from air traffic control (ATC)? The open cabin 

door now becomes a higher risk factor. The problem has 

not changed, but the perception of risk a pilot assigns it 

changes because of the multitude of ongoing tasks and 

the environment. Experience, discipline, awareness, and 

knowledge will influence how a pilot ranks a problem. 

Choose (a Course of Action)

After the problem has been identified and its impact 

estimated, the pilot must determine the desirable outcome 

and choose a course of action. In the case of the multiengine 

pilot given the simulated failed engine, the desired objective 

is to safely land the airplane. 

Identify (Solutions)

The pilot formulates a plan that will take him or her to the 

objective. Sometimes, there may be only one course of action 

available. In the case of the engine failure, already at 500 

feet or below, the pilot solves the problem by identifying 

one or more solutions that lead to a successful outcome. It is 

important for the pilot not to become fixated on the process 

to the exclusion of making a decision. 

Do (the Necessary Actions)

Once pathways to resolution are identified, the pilot selects 

the most suitable one for the situation. The multiengine pilot 

given the simulated failed engine must now safely land the 

aircraft. 

Evaluate (the Effect of the Action) 

Finally, after implementing a solution, evaluate the decision 

to see if it was correct. If the action taken does not provide 

the desired results, the process may have to be repeated.

Decision-Making in a Dynamic 

Environment 

The common approach to decision-making has been through 

the use of analytical models such as 5P, 3P, OODA, and 

DECIDE. Good decisions result when pilots gather all 

available information, review it, analyze the options, rate the 

options, select a course of action, and evaluate that course of 

action for correctness.

In some situations, there isn’t always time to make decisions 

based on analytical decision-making skills. A good example 

is a quarterback whose actions are based upon a highly fluid 

and changing situation. He intends to execute a plan, but new 

circumstances dictate decision-making on the fly. This type 

of decision-making is called automatic decision-making or 

naturalized decision-making. [Figure 17-11B]
17-20

Automatic Decision-Making 

In an emergency situation, a pilot might not survive if he or 

she rigorously applied analytical models to every decision 

made; there is not enough time to go through all the options. 

But under these circumstances does he or she find the best 

possible solution to every problem? 

For the past several decades, research into how people 

actually make decisions has revealed that when pressed for 

time, experts faced with a task loaded with uncertainty, first 

assess whether the situation strikes them as familiar. Rather 

than comparing the pros and cons of different approaches, 

they quickly imagine how one or a few possible courses of 

action in such situations will play out. Experts take the first 

workable option they can find. While it may not be the best of 

all possible choices, it often yields remarkably good results.

The terms naturalistic and automatic decision-making have 

been coined to describe this type of decision-making. The 

ability to make automatic decisions holds true for a range 

of experts from fire fighters to chess players. It appears the 

expert’s ability hinges on the recognition of patterns and 

consistencies that clarify options in complex situations. 

Experts appear to make provisional sense of a situation, 

without actually reaching a decision, by launching experiencebased actions that in turn trigger creative revisions. 

This is a reflexive type of decision-making anchored in 

training and experience and is most often used in times of 

emergencies when there is no time to practice analytical 

decision-making. Naturalistic or automatic decision-making 

improves with training and experience, and a pilot will find 

himself or herself using a combination of decision-making 

tools that correlate with individual experience and training.

Operational Pitfalls

Although more experienced pilots are likely to make more 

automatic decisions, there are tendencies or operational 

pitfalls that come with the development of pilot experience. 

These are classic behavioral traps into which pilots have 

been known to fall. More experienced pilots (as a rule) try 

to complete a flight as planned, please passengers, and meet 

schedules. The desire to meet these goals can have an adverse 

effect on safety and contribute to an unrealistic assessment 

of piloting skills. All experienced pilots have fallen prey to, 

or have been tempted by, one or more of these tendencies in 

their flying careers. These dangerous tendencies or behavior 

patterns, which must be identified and eliminated, include 

the operational pitfalls shown in Figure 17-12.

Stress Management

Everyone is stressed to some degree almost all of the time. A 

certain amount of stress is good since it keeps a person alert 

and prevents complacency. Effects of stress are cumulative 

and, if the pilot does not cope with them in an appropriate 

way, they can eventually add up to an intolerable burden. 

Performance generally increases with the onset of stress, 

peaks, and then begins to fall off rapidly as stress levels 

exceed a person’s ability to cope. The ability to make 

effective decisions during flight can be impaired by stress. 

There are two categories of stress—acute and chronic. These 

are both explained in Chapter 16, Aeromedical Factors. 

Factors referred to as stressors can increase a pilot’s risk of 

error in the flight deck. [Figure 17-13] Remember the cabin 

door that suddenly opened in flight on the Mooney climbing 

through 1,500 feet on a clear sunny day? It may startle the 

pilot, but the stress would wane when it became apparent 

the situation was not a serious hazard. Yet, if the cabin door 

opened in IMC conditions, the stress level makes significant 

impact on the pilot’s ability to cope with simple tasks. The 

key to stress management is to stop, think, and analyze before 

jumping to a conclusion. There is usually time to think before 

drawing unnecessary conclusions. 

There are several techniques to help manage the accumulation 

of life stresses and prevent stress overload. For example, to 

help reduce stress levels, set aside time for relaxation each 

day or maintain a program of physical fitness. To prevent 

stress overload, learn to manage time more effectively to 

avoid pressures imposed by getting behind schedule and not 

meeting deadlines. 

Use of Resources

To make informed decisions during flight operations, a pilot 

must also become aware of the resources found inside and 

outside the flight deck. Since useful tools and sources of 

information may not always be readily apparent, learning 

to recognize these resources is an essential part of ADM 

training. Resources must not only be identified, but a pilot 

must also develop the skills to evaluate whether there is 

time to use a particular resource and the impact its use will 

have upon the safety of flight. For example, the assistance 

of ATC may be very useful if a pilot becomes lost, but in 

an emergency situation, there may be no time available to 

contact ATC.

Internal Resources

One of the most underutilized resources may be the person in 

the right seat, even if the passenger has no flying experience. 

When appropriate, the PIC can ask passengers to assist with 

certain tasks, such as watching for traffic or reading checklist 

items. Some other ways a passenger can assist: 

• Provide information in an irregular situation, especially 

if familiar with flying. A strange smell or sound may 

alert a passenger to a potential problem. 
17-21

Figure 17-12. Typical operational pitfalls requiring pilot awareness.

Operational Pitfalls

Peer Pressure

Poor decision-making may be based upon an emotional response to peers, rather than evaluating a situation objectively.

Mind Set

A pilot displays mind set through an inability to recognize and cope with changes in a given situation. 

Get-there-itis

This disposition impairs pilot judgment through a fixation on the original goal or destination, combined with a disregard for any 

alternative course of action.

Duck-Under Syndrome

A pilot may be tempted to make it into an airport by descending below minimums during an approach. There may be a belief that 

there is a built-in margin of error in every approach procedure, or a pilot may want to admit that the landing cannot be completed 

and a missed approach must be initiated.

Scud Running

This occurs when a pilot tries to maintain visual contact with the terrain at low altitudes while instrument conditions exist.

Continuing Visual Flight Rules (VFR) into Instrument Conditions

Spatial disorientation or collision with ground/obstacles may occur when a pilot continues VFR into instrument conditions. This can 

be even more dangerous if the pilot is not instrument rated or current.

Getting Behind the Aircraft

This pitfall can be caused by allowing events or the situation to control pilot actions. A constant state of surprise at what happens 

next may be exhibited when the pilot is getting behind the aircraft.

Loss of Positional or Situational Awareness

In extreme cases, when a pilot gets behind the aircraft, a loss of positional or situational awareness may result. The pilot may not 

know the aircraft’s geographical location, or may be unable to recognize deteriorating circumstances.

Operating Without Adequate Fuel Reserves

Ignoring minimum fuel reserve requirements is generally the result of overconfidence, lack of flight planning, or disregarding 

applicable regulations.

Descent Below the Minimum En Route Altitude

The duck-under syndrome, as mentioned above, can also occur during the en route portion of an IFR flight.

Flying Outside the Envelope

The assumed high performance capability of a particular aircraft may cause a mistaken belief that it can meet the demands 

imposed by a pilot’s overestimated flying skills. 

Neglect of Flight Planning, Preflight Inspections, and Checklists

A pilot may rely on short- and long-term memory, regular flying skills, and familiar routes instead of established procedures and 

published checklists. This can be particularly true of experienced pilots.

Stressors

Environmental

Conditions associated with the environment, such as 

temperature and humidity extremes, noise, vibration, and lack 

of oxygen.

Physiological Stress

Physical conditions, such as fatigue, lack of physical fitness, 

sleep loss, missed meals (leading to low blood sugar levels), 

and illness.

Psychological Stress

Social or emotional factors, such as a death in the family, a 

divorce, a sick child, or a demotion at work. This type of stress 

may also be related to mental workload, such as analyzing a 

problem, navigating an aircraft, or making decisions.

Figure 17-13. System stressors. Environmental, physiological, and 

psychological stress are factors which affect decision-making skills. 

These stressors have a profound impact especially during periods 

of high workload.
17-22

Figure 17-14. When possible, have a passenger reconfirm that critical tasks are completed.

• Confirm after the pilot that the landing gear is 

down. 

• Learn to look at the altimeter for a given altitude in a 

descent.

• Listen to logic or lack of logic.

Also, the process of a verbal briefing (which can happen 

whether or not passengers are aboard) can help the PIC in 

the decision-making process. For example, assume a pilot 

provides a lone passenger a briefing of the forecast landing 

weather before departure. When the Automatic Terminal 

Information Service (ATIS) is picked up, the weather has 

significantly changed. The discussion of this forecast change 

can lead the pilot to reexamine his or her activities and 

decision-making. [Figure 17-14] Other valuable internal 

resources include ingenuity, aviation knowledge, and flying 

skill. Pilots can increase flight deck resources by improving 

these characteristics.

 

When flying alone, another internal resource is verbal 

communication. It has been established that verbal 

communication reinforces an activity; touching an object 

while communicating further enhances the probability an 

activity has been accomplished. For this reason, many solo 

pilots read the checklist out loud; when they reach critical 

items, they touch the switch or control. For example, to 

ascertain the landing gear is down, the pilot can read the 

checklist. But, if he or she touches the gear handle during the 

process, a safe extension of the landing gear is confirmed.

It is necessary for a pilot to have a thorough understanding 

of all the equipment and systems in the aircraft being flown. 

Lack of knowledge, such as knowing if the oil pressure 

gauge is direct reading or uses a sensor, is the difference 

between making a wise decision or poor one that leads to a 

tragic error. 

Checklists are essential flight deck internal resources. They 

are used to verify the aircraft instruments and systems are 

checked, set, and operating properly, as well as ensuring 

the proper procedures are performed if there is a system 

malfunction or inflight emergency. Students reluctant to 

use checklists can be reminded that pilots at all levels of 

experience refer to checklists, and that the more advanced the 

aircraft is, the more crucial checklists become. In addition, the 

pilot’s operating handbook (POH) is required to be carried on 

board the aircraft and is essential for accurate flight planning 

and resolving inflight equipment malfunctions. However, the 

most valuable resource a pilot has is the ability to manage 

workload whether alone or with others.

External Resources

Air traffic controllers and flight service specialists are the best 

external resources during flight. In order to promote the safe, 

orderly flow of air traffic around airports and, along flight 

routes, the ATC provides pilots with traffic advisories, radar 

vectors, and assistance in emergency situations. Although 

it is the PIC’s responsibility to make the flight as safe as 

possible, a pilot with a problem can request assistance from 

ATC. [Figure 17-15] For example, if a pilot needs to level 

off, be given a vector, or decrease speed, ATC assists and 
17-23

Figure 17-15. Controllers work to make flights as safe as 

possible.

becomes integrated as part of the crew. The services provided 

by ATC can not only decrease pilot workload, but also help 

pilots make informed inflight decisions.

The FSS are air traffic facilities that provide pilot briefing, 

en route communications, VFR search and rescue services, 

assist lost aircraft and aircraft in emergency situations, relay 

ATC clearances, originate Notices to Airmen (NOTAM), 

broadcast aviation weather and National Airspace System 

(NAS) information, receive and process IFR flight plans, 

and monitor navigational aids (NAVAIDs). In addition, at 

selected locations, FSSs provide En Route Flight Advisory 

Service (Flight Watch), issue airport advisories, and advise 

Customs and Immigration of transborder flights. Selected 

FSSs in Alaska also provide TWEB recordings and take 

weather observations.

Another external resource available to pilots is the VHF 

Direction Finder (VHF/DF). This is one of the common 

systems that helps pilots without their being aware of its 

operation. FAA facilities that provide VHF/DF service are 

identified in the A/FD. DF equipment has long been used 

to locate lost aircraft and to guide aircraft to areas of good 

weather or to airports. DF instrument approaches may be 

given to aircraft in a distress or urgency condition.

Experience has shown that most emergencies requiring DF 

assistance involve pilots with little flight experience. With this 

in mind, DF approach procedures provide maximum flight 

stability in the approach by using small turns, and wingslevel descents. The DF specialist will give the pilot headings 

to fly and tell the pilot when to begin descent. If followed, 

the headings will lead the aircraft to a predetermined point 

such as the DF station or an airport. To become familiar with 

the procedures and other benefits of DF, pilots are urged to 

request practice DF guidance and approaches in VFR weather 

conditions.

Situational Awareness

Situational awareness is the accurate perception and 

understanding of all the factors and conditions within 

the five fundamental risk elements (flight, pilot, aircraft, 

environment, and type of operation that comprise any given 

aviation situation) that affect safety before, during, and after 

the flight. Monitoring radio communications for traffic, 

weather discussion, and ATC communication can enhance 

situational awareness by helping the pilot develop a mental 

picture of what is happening.

Maintaining situational awareness requires an understanding 

of the relative significance of all flight related factors and their 

future impact on the flight. When a pilot understands what is 

going on and has an overview of the total operation, he or she 

is not fixated on one perceived significant factor. Not only 

is it important for a pilot to know the aircraft’s geographical 

location, it is also important he or she understand what is 

happening. For instance, while flying above Richmond, 

Virginia, toward Dulles Airport or Leesburg, the pilot 

should know why he or she is being vectored and be able to 

anticipate spatial location. A pilot who is simply making turns 

without understanding why has added an additional burden 

to his or her management in the event of an emergency. To 

maintain situational awareness, all of the skills involved in 

ADM are used. 

Obstacles to Maintaining Situational Awareness

Fatigue, stress, and work overload can cause a pilot to fixate 

on a single perceived important item and reduce an overall 

situational awareness of the flight. A contributing factor 

in many accidents is a distraction that diverts the pilot’s 

attention from monitoring the instruments or scanning outside 

the aircraft. Many flight deck distractions begin as a minor 

problem, such as a gauge that is not reading correctly, but 

result in accidents as the pilot diverts attention to the perceived 

problem and neglects to properly control the aircraft.

Workload Management

Effective workload management ensures essential operations 

are accomplished by planning, prioritizing, and sequencing 

tasks to avoid work overload. [Figure 17-16] As experience 

is gained, a pilot learns to recognize future workload 

requirements and can prepare for high workload periods 

during times of low workload. Reviewing the appropriate 

chart and setting radio frequencies well in advance of when 

they are needed helps reduce workload as the flight nears the 

airport. In addition, a pilot should listen to ATIS, Automated 

Surface Observing System (ASOS), or Automated Weather 
17-24

Figure 17-16. Balancing workloads can be a difficult task.

Figure 17-17. The pilot has a certain capacity of doing work and handling tasks. However, there is a point where the tasking exceeds the 

pilot’s capability. When this happens, tasks are either not done properly or some are not done at all.

Preflight

Takeoff

Cruise

Approach & Landing

Time

Task Load

High

Low

Pilot Capabilities

Task Requirements

Observing System (AWOS), if available, and then monitor 

the tower frequency or Common Traffic Advisory Frequency 

(CTAF) to get a good idea of what traffic conditions to 

expect. Checklists should be performed well in advance so 

there is time to focus on traffic and ATC instructions. These 

procedures are especially important prior to entering a highdensity traffic area, such as Class B airspace. 

Recognizing a work overload situation is also an important 

component of managing workload. The first effect of 

high workload is that the pilot may be working harder but 

accomplishing less. As workload increases, attention cannot 

be devoted to several tasks at one time, and the pilot may 

begin to focus on one item. When a pilot becomes task 

saturated, there is no awareness of input from various sources, 

so decisions may be made on incomplete information and the 

possibility of error increases. [Figure 17-17]

When a work overload situation exists, a pilot needs to stop, 

think, slow down, and prioritize. It is important to understand 

how to decrease workload. For example, in the case of the 

cabin door that opened in VFR flight, the impact on workload 

should be insignificant. If the cabin door opens under IFR 

different conditions, its impact on workload will change. 

Therefore, placing a situation in the proper perspective, 

remaining calm, and thinking rationally are key elements in 

reducing stress and increasing the capacity to fly safely. This 

ability depends upon experience, discipline, and training.

Managing Risks

The ability to manage risk begins with preparation. Here are 

some things a pilot can do to manage overall risk: 

• Assess the flight’s risk based upon experience. 

Use some form of risk assessment. For example, if 

the weather is marginal and the pilot has low IMC 

training, it is probably a good idea to cancel the 

flight.
17-25

• Brief passengers using the SAFETY list:

S Seat belts fastened for taxi, takeoff, landing

 Shoulder harness fastened for takeoff, landing

 Seat position adjusted and locked in place

A Air vents (location and operation)

 All environmental controls (discussed)

 Action in case of any passenger discomfort

F Fire extinguisher (location and operation)

E Exit doors (how to secure; how to open)

 Emergency evacuation plan

 Emergency/survival kit (location and contents)

T Traffic (scanning, spotting, notifying pilot)

 Talking, (“sterile flight deck” expectations)

Y Your questions? (Speak up!) 

• In addition to the SAFETY list, discuss with 

passengers whether or not smoking is permitted, flight 

route altitudes, time en route, destination, weather 

during flight, expected weather at the destination, 

controls and what they do, and the general capabilities 

and limitations of the aircraft.

• Use a sterile flight deck (one that is completely silent 

with no pilot communication with passengers or by 

passengers) from the time of departure to the first 

intermediate altitude and clearance from the local 

airspace. 

• Use a sterile flight deck during arrival from the 

first radar vector for approach or descent for the 

approach.

• Keep the passengers informed during times when the 

workload is low.

• Consider using the passenger in the right seat for 

simple tasks such as holding the chart. This relieves 

the pilot of a task. 

Automation

In the GA community, an automated aircraft is generally 

comprised of an integrated advanced avionics system 

consisting of a primary flight display (PFD), a multifunction 

flight display (MFD) including an instrument-certified Global 

Positioning System (GPS) with traffic and terrain graphics, 

and a fully integrated autopilot. This type of aircraft is 

commonly known as an advanced avionics aircraft. In an 

advanced avionics aircraft, there are typically two display 

(computer) screens, PFD (left display screen) and the 

MFD.

Automation is the single most important advance in aviation 

technologies. Electronic flight displays (EFDs) have made 

vast improvements in how information is displayed and 

what information is available to the pilot. Pilots can access 

electronic databases that contain all of the information 

traditionally contained in multiple handbooks, reducing 

clutter in the flight deck. [Figure 17-18]

Multifunction displays (MFDs) are capable of displaying 

moving maps that mirror sectional charts. These detailed 

displays depict all airspace, including Temporary Flight 

Restrictions (TFRs). MFDs are so descriptive that many 

pilots fall into the trap of relying solely on the moving 

maps for navigation. Pilots also draw upon the database to 

familiarize themselves with departure and destination airport 

information.

More pilots now rely on electronic databases for flight 

planning and use automated flight planning tools rather than 

planning the flight by the traditional methods of laying out 

charts, drawing the course, identifying navigation points 

(assuming a VFR flight), and using the POH to figure out 

the weight and balance and performance charts. Whichever 

method a pilot chooses to plan a flight, it is important to 

remember to check and confirm calculations

Although automation has made flying safer, automated 

systems can make some errors more evident, and sometimes 

hide other errors or make them less evident. There are concerns 

about the effect of automation on pilots. In a study published 

in 1995, the British Airline Pilots Association officially 

voiced its concern that “Airline pilots increasingly lack ‘basic 

flying skills’ as a result of reliance on automation.” 

This reliance on automation translates into a lack of basic 

flying skills that may affect the pilot’s ability to cope with 

an inflight emergency, such as sudden mechanical failure. 

The worry that pilots are becoming too reliant on automated 

systems and are not being encouraged or trained to fly 

manually has grown with the increase in the number of MFD 

flight decks.

As automated flight decks began entering everyday line 

operations, instructors and check airmen grew concerned 

about some of the unanticipated side effects. Despite the 

promise of reducing human mistakes, the flight managers 

reported the automation actually created much larger errors 

at times. In the terminal environment, the workload in an 

automated flight deck actually seemed higher than in the older 

analog flight decks. At other times, the automation seemed 

to lull the flight crews into complacency. Over time, concern 

surfaced that the manual flying skills of the automated flight 
17-26

Figure 16-10. Electronic Flight instrumentation come in many systems and provides a myriad of information to the pilot.

Figure 17-18. Electronic flight instrumentation comes in many systems and provides a myriad of information to the pilot.
17-27

crews deteriorated due to over-reliance on computers. The 

flight crew managers said they worried that pilots would have 

less “stick-and-rudder” proficiency when those skills were 

needed to manually resume direct control of the aircraft. 

A major study was conducted to evaluate the performance 

of two groups of pilots. The control group was composed 

of pilots who flew an older version of a common twinjet airliner equipped with analog instrumentation and the 

experimental group was composed of pilots who flew the 

same aircraft, but newer models equipped with an electronic 

flight instrument system (EFIS) and a flight management 

system (FMS). The pilots were evaluated in maintaining 

aircraft parameters such as heading, altitude, airspeed, 

glideslope, and localizer deviations, as well as pilot control 

inputs. These were recorded during a variety of normal, 

abnormal, and emergency maneuvers during 4 hours of 

simulator sessions. 

Results of the Study

When pilots who had flown EFIS for several years were 

required to fly various maneuvers manually, the aircraft 

parameters and flight control inputs clearly showed some 

erosion of flying skills. During normal maneuvers such as 

turns to headings without a flight director, the EFIS group 

exhibited somewhat greater deviations than the analog group. 

Most of the time, the deviations were within the practical test 

standards (PTS), but the pilots definitely did not keep on the 

localizer and glideslope as smoothly as the analog group. 

The differences in hand-flying skills between the two groups 

became more significant during abnormal maneuvers such 

as slam-dunks. When given close crossing restrictions, the 

analog crews were more adept at the mental math and usually 

maneuvered the aircraft in a smoother manner to make the 

restriction. On the other hand, the EFIS crews tended to go 

“heads down” and tried to solve the crossing restriction on 

the FMS. [Figure 17-19]

Another situation used in the simulator experiment reflected 

real world changes in approach that are common and can 

be assigned on short notice. Once again, the analog crews 

transitioned more easily to the parallel runway’s localizer, 

whereas the EFIS crews had a much more difficult time, with 

the pilot going head down for a significant amount of time 

trying to program the new approach into the FMS. 

While a pilot’s lack of familiarity with the EFIS is often 

an issue, the approach would have been made easier by 

disengaging the automated system and manually flying the 

approach. At the time of this study, the general guidelines 

in the industry were to let the automated system do as much 

of the flying as possible. That view has since changed and 

it is recommended that pilots use their best judgment when 

choosing which level of automation will most efficiently 

do the task considering the workload and situational 

awareness.

Emergency maneuvers clearly broadened the difference in 

manual flying skills between the two groups. In general, the 

analog pilots tended to fly raw data, so when they were given 

an emergency such as an engine failure and were instructed 

to fly the maneuver without a flight director, they performed 

it expertly. By contrast, SOP for EFIS operations at the time 

was to use the flight director. When EFIS crews had their 

flight directors disabled, their eye scan again began a more 

erratic searching pattern and their manual flying subsequently 

suffered. 

Those who reviewed the data saw that the EFIS pilots who 

better managed the automation also had better flying skills. 

While the data did not reveal whether those skills preceded 

or followed automation, it did indicate that automation 

management needed to be improved. Recommended “best 

practices” and procedures have remedied some of the earlier 

problems with automation.

Pilots need to maintain their flight skills and ability to 

maneuver aircraft manually within the standards set forth in 

the PTS. It is recommended that pilots of automated aircraft 

occasionally disengage the automation and manually fly 

the aircraft to maintain stick-and-rudder proficiency. It 

is imperative pilots understand that the EFD adds to the 

overall quality of the flight experience, but it can also lead to 

catastrophe if not utilized properly. At no time is the moving 

map meant to substitute for a VFR sectional or low altitude 

en route chart. 
17-28

OBS

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XPDR 5537 IDNT LCL 10:12:34

VOR 1

270°

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TAS 106KT

OAT 7°C

ALERTS

NAV1 108.00 113.00 NAV2 108.00 110.60 134.000 118.000 COM1

123.800 118.000 COM2

WPT _ _ _ _ _ _ DIS _ _ ._ NM DTK _ _ _° TRK 360°

ALERT

Figure 16-11. Figure 16-11 illustrates two similar cockpits equipped with the same information two different ways, analog on the left 

and digital on the right. What are they indicating? Chances are that the analog pilot will review the display on the left before the

display on the right. Conversely the digitally trained pilot will review the instrument panel on the right side first.

Figure 17-19. Two similar flight decks equipped with the same information two different ways, analog and digital. What are they indicating? 

Chances are that the analog pilot will review the top display before the bottom display. Conversely, the digitally trained pilot will review 

the instrument panel on the bottom first.
17-29

Figure 17-20. An example of an autopilot system.

Equipment Use

Autopilot Systems

In a single-pilot environment, an autopilot system can greatly 

reduce workload. [Figure 17-20] As a result, the pilot is free 

to focus his or her attention on other flight deck duties. This 

can improve situational awareness and reduce the possibility 

of a CFIT accident. While the addition of an autopilot may 

certainly be considered a risk control measure, the real 

challenge comes in determining the impact of an inoperative 

unit. If the autopilot is known to be inoperative prior to 

departure, this may factor into the evaluation other risks.

For example, the pilot may be planning for a VHF 

omnidirectional range (VOR) approach down to minimums 

on a dark night into an unfamiliar airport. In such a case, the 

pilot may have been relying heavily on a functioning autopilot 

capable of flying a coupled approach. This would free the 

pilot to monitor aircraft performance. A malfunctioning 

autopilot could be the single factor that takes this from a 

medium to a serious risk. At this point, an alternative needs 

to be considered. On the other hand, if the autopilot were to 

fail at a critical (high workload) portion of this same flight, 

the pilot must be prepared to take action. Instead of simply 

being an inconvenience, this could quickly turn into an 

emergency if not properly handled. The best way to ensure 

a pilot is prepared for such an event is to carefully study the 

issue prior to departure and determine well in advance how 

an autopilot failure is to be handled.

Familiarity

As previously discussed, pilot familiarity with all equipment 

is critical in optimizing both safety and efficiency. If a pilot is 

unfamiliar with any aircraft systems, this will add to workload 

and may contribute to a loss of situational awareness. This 

level of proficiency is critical and should be looked upon 

as a requirement, not unlike carrying an adequate supply of 

fuel. As a result, pilots should not look upon unfamiliarity 

with the aircraft and its systems as a risk control measure, 

but instead as a hazard with high risk potential. Discipline 

is key to success. 

Respect for Onboard Systems

Automation can assist the pilot in many ways, but a thorough 

understanding of the system(s) in use is essential to gaining 

the benefits it can offer. Understanding leads to respect 

which is achieved through discipline and the mastery of the 

onboard systems. It is important to fly the airplane using 

minimal information from the primary flight display (PFD). 

This includes turns, climbs, descents, and being able to fly 

approaches. 

Reinforcement of Onboard Suites

The use of an electronic flight display may not seem 

intuitive, but competency becomes better with understanding 

and practice. Computer-based software and incremental 

training help the pilot become comfortable with the onboard 

suites. Then the pilot needs to practice what was learned 

in order to gain experience. Reinforcement not only yields 

dividends in the use of automation, it also reduces workload 

significantly.

Getting Beyond Rote Workmanship

The key to working effectively with automation is getting 

beyond the sequential process of executing an action. If a 

pilot has to analyze what key to push next, or always uses 

the same sequence of keystrokes when others are available, 

he or she may be trapped in a rote process. This mechanical 

process indicates a shallow understanding of the system. 

Again, the desire is to become competent and know what to 

do without having to think about,“what keystroke is next.” 

Operating the system with competency and comprehension 

benefits a pilot when situations become more diverse and 

tasks increase. 

Understand the Platform 

Contrary to popular belief, flight in aircraft equipped with 

different electronic management suites requires the same 

attention as aircraft equipped with analog instrumentation 

and a conventional suite of avionics. The pilot should review 

and understand the different ways in which EFD are used in 

a particular aircraft. [Figure 17-21]

Two simple rules for use of an EFD:

• Be able to fly the aircraft to the standards in the PTS. 

Although this may seem insignificant, knowing how to 

fly the aircraft to a standard makes a pilot’s airmanship 

smoother and allows him or her more time to attend 

to the system instead of managing multiple tasks.

• Read and understand the installed electronic flight 

systems manuals to include the use of the autopilot 

and the other onboard electronic management tools. 
17-30

Figure 17-21. Examples of different platforms. Top to bottom are the 

Beechcraft Baron G58, Cirrus SR22, and Cirrus Entega.

Managing Aircraft Automation 

Before any pilot can master aircraft automation, he or she 

must first know how to fly the aircraft. Maneuvers training 

remains an important component of flight training because 

almost 40 percent of all GA accidents take place in the 

landing phase, one realm of flight that still does not involve 

programming a computer to execute. Another 15 percent of 

all GA accidents occurs during takeoff and initial climb.

An advanced avionics safety issue identified by the FAA 

concerns pilots who apparently develop an unwarranted overreliance in their avionics and the aircraft, believing that the 

equipment will compensate for pilot shortcomings. Related 

to the over-reliance is the role of ADM, which is probably 

the most significant factor in the GA accident record of high 

performance aircraft used for cross country flight. The FAA 

advanced avionics aircraft Safety Study found that poor 

decision-making seems to afflict new advanced avionics 

pilots at a rate higher than that of GA as a whole. The review 

of advanced avionics accidents cited in this study shows the 

majority are not caused by something directly related to the 

aircraft, but by the pilot’s lack of experience and a chain of 

poor decisions. One consistent theme in many of the fatal 

accidents is continued VFR flight into IMC.

Thus, pilot skills for normal and emergency operations hinge 

not only on mechanical manipulation of the stick and rudder, 

but also include the mental mastery of the EFD. Three key 

flight management skills are needed to fly the advanced 

avionics safely: information, automation, and risk. 

Information Management

For the newly transitioning pilot, the PFD, MFD, and GPS/

VHF navigator screens seem to offer too much information 

presented in colorful menus and submenus. In fact, the pilot 

may be drowning in information but unable to find a specific 

piece of information. It might be helpful to remember these 

systems are similar to computers which store some folders 

on a desktop and some within a hierarchy.

The first critical information management skill for flying with 

advanced avionics is to understand the system at a conceptual 

level. Remembering how the system is organized helps the 

pilot manage the available information. It is important to 

understanding that learning knob-and-dial procedures is not 

enough. Learning more about how advanced avionics systems 

work leads to better memory for procedures and allows pilots 

to solve problems they have not seen before.

There are also limits to understanding. It is generally 

impossible to understand all of the behaviors of a complex 

avionics system. Knowing to expect surprises, and to 

continually learn new things is more effective than attempting 

to memorize mechanical manipulation of the knobs. 

Simulation software and books on the specific system used 

are of great value.

The second critical information management skill is stop, 

look, and read. Pilots new to advanced avionics often become 

fixated on the knobs and try to memorize each and every 

sequence of button pushes, pulls, and turns. A far better 

strategy for accessing and managing the information available 

in advanced avionics computers is to stop, look, and read. 

Reading before pushing, pulling, or twisting can often save 

a pilot some trouble.

Once behind the display screens on an advanced avionics 

aircraft, the pilot’s goal is to meter, manage, and prioritize the 
17-31

information flow to accomplish specific tasks. Certificated 

flight instructors (CFIs) as well as pilots transitioning to 

advanced avionics will find it helpful to corral the information 

flow. This is possible through such tactics as configuring the 

aspects of the PFD and MFD screens according to personal 

preferences. For example, most systems offer map orientation 

options that include “north up,” “track up,” “DTK” (desired 

track up), and “heading up.” Another tactic is to decide, when 

possible, how much (or how little) information to display. 

Pilots can also tailor the information displayed to suit the 

needs of a specific flight. 

Information flow can also be managed for a specific 

operation. The pilot has the ability to prioritize information 

for a timely display of exactly the information needed for any 

given flight operation. Examples of managing information 

display for a specific operation include:

• Program map scale settings for en route versus 

terminal area operation.

• Utilize the terrain awareness page on the MFD for a 

night or IMC flight in or near the mountains.

• Use the nearest airports inset on the PFD at night or 

over inhospitable terrain.

• Program the weather datalink set to show echoes and 

METAR status flags.

Enhanced Situational Awareness

An advanced avionics aircraft offers increased safety with 

enhanced situational awareness. Although aircraft flight 

manuals (AFM) explicitly prohibit using the moving map, 

topography, terrain awareness, traffic, and weather datalink 

displays as the primary data source, these tools nonetheless 

give the pilot unprecedented information for enhanced 

situational awareness. Without a well-planned information 

management strategy, these tools also make it easy for an 

unwary pilot to slide into the complacent role of passenger 

in command.

Consider the pilot whose navigational information 

management strategy consists solely of following the 

magenta line on the moving map. He or she can easily fly 

into geographic or regulatory disaster, if the straight-line GPS 

course goes through high terrain or prohibited airspace, or if 

the moving map display fails.

A good strategy for maintaining situational awareness 

information management should include practices that help 

ensure that awareness is enhanced by the use of automation, 

not diminished. Two basic procedures are to always doublecheck the system and verbal callouts. At a minimum, ensure 

the presentation makes sense. Was the correct destination fed 

into the navigation system? Callouts—even for single-pilot 

operations—are an excellent way to maintain situational 

awareness as well as manage information. 

Other ways to maintain situational awareness include:

• Perform verification check of all programming. Before 

departure, check all information programmed while 

on the ground. 

• Check the flight routing. Before departure, ensure all 

routing matches the planned flight route. Enter the 

planned route and legs, to include headings and leg 

length, on a paper log. Use this log to evaluate what 

has been programmed. If the two do not match, do not 

assume the computer data is correct, double check the 

computer entry. 

• Verify waypoints. 

• Make use of all onboard navigation equipment. For 

example, use VOR to back up GPS and vice versa.

• Match the use of the automated system with pilot 

proficiency. Stay within personal limitations. 

• Plan a realistic flight route to maintain situational 

awareness. For example, although the onboard 

equipment allows a direct flight from Denver, 

Colorado, to Destin, Florida, the likelihood of 

rerouting around Eglin Air Force Base’s airspace is 

high. 

• Be ready to verify computer data entries. For example, 

incorrect keystrokes could lead to loss of situational 

awareness because the pilot may not recognize errors 

made during a high workload period.

Automation Management

Advanced avionics offer multiple levels of automation, from 

strictly manual flight to highly automated flight. No one level 

of automation is appropriate for all flight situations, but in 

order to avoid potentially dangerous distractions when flying 

with advanced avionics, the pilot must know how to manage 

the course deviation indicator (CDI), the navigation source, 

and the autopilot. It is important for a pilot to know the 

peculiarities of the particular automated system being used. 

This ensures the pilot knows what to expect, how to monitor 

for proper operation, and promptly take appropriate action if 

the system does not perform as expected.

For example, at the most basic level, managing the autopilot 

means knowing at all times which modes are engaged 

and which modes are armed to engage. The pilot needs to 

verify that armed functions (e.g., navigation tracking or 

altitude capture) engage at the appropriate time. Automation 

management is another good place to practice the callout 
17-32

technique, especially after arming the system to make a 

change in course or altitude.

In advanced avionics aircraft, proper automation management 

also requires a thorough understanding of how the autopilot 

interacts with the other systems. For example, with some 

autopilots, changing the navigation source on the e-HSI from 

GPS to LOC or VOR while the autopilot is engaged in NAV 

(course tracking mode) will cause the autopilot’s NAV mode 

to disengage. The autopilot’s lateral control will default to 

ROL (wing level) until the pilot takes action to reengage the 

NAV mode to track the desired navigation source.

Risk Management

Risk management is the last of the three flight management 

skills needed for mastery of the glass flight deck aircraft. The 

enhanced situational awareness and automation capabilities 

offered by a glass flight deck airplane vastly expand its safety 

and utility, especially for personal transportation use. At the 

same time, there is some risk that lighter workloads could 

lead to complacency.

Humans are characteristically poor monitors of automated 

systems. When asked to passively monitor an automated 

system for faults, abnormalities, or other infrequent events, 

humans perform poorly. The more reliable the system, the 

poorer the human performance. For example, the pilot only 

monitors a backup alert system, rather than the situation 

that the alert system is designed to safeguard. It is a paradox 

of automation that technically advanced avionics can both 

increase and decrease pilot awareness.

It is important to remember that electronic flight displays do 

not replace basic flight knowledge and skills. They are a tool 

for improving flight safety. Risk increases when the pilot 

believes the gadgets will compensate for lack of skill and 

knowledge. It is especially important to recognize there are 

limits to what the electronic systems in any light GA aircraft 

can do. Being PIC requires sound ADM which sometimes 

means saying “no” to a flight. 

Risk is also increased when the pilot fails to monitor the 

systems. By failing to monitor the systems and failing to 

check the results of the processes, the pilot becomes detached 

from the aircraft operation and slides into the complacent role 

of passenger in command. Complacency led to tragedy in a 

1999 aircraft accident.

In Colombia, a multi-engine aircraft crewed with two pilots 

struck the face of the Andes Mountains. Examination of 

their FMS revealed they entered a waypoint into the FMS 

incorrectly by one degree resulting in a flightpath taking 

them to a point 60 NM off their intended course. The pilots 

were equipped with the proper charts, their route was posted 

on the charts, and they had a paper navigation log indicating 

the direction of each leg. They had all the tools to manage 

and monitor their flight, but instead allowed the automation 

to fly and manage itself. The system did exactly what it was 

programmed to do; it flew on a programmed course into a 

mountain resulting in multiple deaths. The pilots simply failed 

to manage the system and inherently created their own hazard. 

Although this hazard was self-induced, what is notable is 

the risk the pilots created through their own inattention. 

By failing to evaluate each turn made at the direction of 

automation, the pilots maximized risk instead of minimizing 

it. In this case, a totally avoidable accident become a tragedy 

through simple pilot error and complacency. 

For the GA pilot transitioning to automated systems, it is 

helpful to note that all human activity involving technical 

devices entails some element of risk. Knowledge, experience, 

and mission requirements tilt the odds in favor of safe and 

successful flights. The advanced avionics aircraft offers 

many new capabilities and simplifies the basic flying tasks, 

but only if the pilot is properly trained and all the equipment 

is working as advertised. 

Chapter Summary 

This chapter focused on helping the pilot improve his or 

her ADM skills with the goal of mitigating the risk factors 

associated with flight in both classic and automated aircraft. 

In the end, the discussion is not so much about aircraft, but 

about the people who fly them.