1

**Petition for Additional Options for Federal Aviation Administration (FAA) Sponsored Pilot Proficiency Award Programs**  **Approved under provisions of 14 Code of Federal Regulations (CFR) Section 61.56(e) Synopsis**  **:** This petition does not seek a rule change or seek an exemption from a n existing rule. Rather, this petition seeks to enable the FAA and the aviation community to offer expanded options for FAA- sponsored Pilot Proficiency Award Programs under the existing provisions of 14 CFR Part 61, Section 61.56(e ). The petitioner believes that the best means to accomplish this is by revising Advisory Circular (AC) 61 - 91J “WINGS – Pilot Proficiency Program.” **Co -**  **Petitioner:** Robert A. Wright, President

Wright Aviation Solutions LLC 910 Harris Avenue Suite 401 B ellingham, WA 98225 360 - 739 - 3773 flyrawright@yahoo.com **Co -**  **Petitioner:** Kent Ewing, President

Bonanza/Baron Pilot Training, Inc. 1509 Duke of Windsor Road Virginia Beach, VA 23454 757 - 287 - 8749 757 -4 96- 2858 (fax) kentewing@verizon.net **Co -**  **Petitioner interests:** Wright Aviation Solutions LLC is an aviation safety consulting firm. Its President, Robert A. Wright, is a retired member of the FAA executive servi ce whose specialty is advising clients, such as aircraft manufacturers, regarding pilot training improvements to reduce fatal accidents. Bonanza/Baron Pilot Training, Inc. is a leading provider of initial and recurrent training for Beech Bonanza, Baron, and other aircraft models. Its president, Kent Ewing, is a retired naval aviator with decades of experience in combat operations, experime ntal flight test, and military and general aviation flight training. **Pertinent section of 14 CFR Part 61:** Section 61.56(e) and supporting Advisory Circular 61 - 91J, “WINGS – Pilot Proficiency Program.”2

**Relief/enhancement requested and reason for request:** Th e petitioners request that the FAA offer a new WINGS pilot safety education option by amending current Advisory Circular 61 - 91J. The new option would be directed at pilots with defined high activity levels. For those pilots who demonstrate and log such hig h activity, the petitioners believe that they would not require annual dual instruction under the WINGS program . These pilots would, however, be re quired to successfully perform the following requirements: 1. Complete a n ann ual risk management course accepted by th e FAA . 2. R emain accident, incident, and violation free while enrolled in the enhanced WINGS program. 3. Log a minimum number of hours and specific flight events annually for the entire period of their training cycle . 4. Complete a scenario - based skill flight with an authorized instructor every two years, with minimum skill elements specified by the FAA . The petitioners believe that the new WINGS option should recognize that experienced pilots who maintain activity and have high time - in -type generally don’t require as much annual dual instruction as is currently specified in the WINGS program. The petitioners also believe that poor risk management is the underlying root cause of most fatal accidents and that the current WINGS program and flight review do not adequately address risk management. They further believe that the key to increasing WINGS participation is offering an option that would appeal to active experienced pilots. A new WINGS option should embrace events-b ased proficiency The petitioners believe that pilots with specified minimum levels of total flight experience, time in aircraft type, and annual and quarterly flight activity do not require as much annual dual instructions as is currently required under the WINGS program, if pilots elect the WINGS program as an alternate to the flight review. Instead, petitioners believe that the dual instruction interval can be extend ed to at least two years, the current minimum requirement for the flight review specifie d by Section 61.56(c), providing that the participating pilots successfully complete an annual risk management course. The petitioners believe that a new WINGS option for active pilots should require one instructional flight every two years and that, unl ike the current flight review, this should be a structured flight with specified standards for successful completion . The petitioners believe that the flig ht should be scenario - based, emphasizing both basic skills and risk management procedures. For pilots choosing to exercise instrument privileges if they have an instrument rating, the instruction flight should be conducted under instrument flight rules (IFR) and be structured around a typical short cross - country flight in the air traffic system. The instr uctional flight would be more stringent and effective than the current flight review, but would still be less burdensome than the requirements of the current WINGS program. The petitioners’ analysis supporting this proposal and notional details concerning how such a program could be structured are contained in Section VI and Appendix 4 of a paper prepared by co - petitioner Robert Wright in early 2012. That paper, An Analysis of Poor Risk3

Management as a Major Determinant of General Aviation Fatal Accident R oot Causality: Some Pilot Training Implications is contained in this petition following the main body of the text under the section “Supporti ng Documentation.” The petitioners believe that the events- based currency requirements illustrated in this paper should be simplified for the requirements of a new WINGS program option, in order to reduce complexity without sacrificing the events - based structure of the new option. The petitioner’s suggest that the events - based requirements for the new WINGS program for active pilots should include the following elements.

 Annual risk management training – Pilots electing the new WINGS option would take a comprehensive initial risk management course and an annual recurrent course. These courses should emphasize risk m anagement principles and procedures, include a case study, and incorporate a testing element that measures satisfactory completion. Ideally, the initial course should also include elements emphasizing other single - pilot resource management (SRM) skills suc h as automation management, task and workload management, and situation al awareness. The petitioners envision that the ideal delivery method for this training would be on - line courses offered by commercial course providers, although live classroom training could also be an option.  Accident, incident, and violation free operation during program participation – Participants in the new WINGS option should be able to demonstrate an on -going track record of safety performance in order to remain in the program.  Events-based maintenance of currency – Participants in the new WINGS option must demonstrate a continuous level of activity that will maintain required flight proficiency. The petitioners suggest the following as broad guidelines. The FAA, with assistance f rom the aviation community, may wish to set the event thresholds based on further analysis of accident and other safety data. o Annual flight time minimums – The petitioners believe that participants in the new WINGS option must fly at least 50 - 100 hours per year in order to ensure that proficiency is maintained. o Quarterly flight time and event minimums – The petitioners believe that the currency minimums specified in Sections 61.57 are not adequate for participants in the new WINGS option. We propose that p articipants must complete and log at least 8 hours and 10 takeoffs and landings each calendar quarter to remain in the program. Instrument rating holders wishing to exercise instrument privileges should complete and log at least 4 i nstrument approaches per quarter. o Additional event requirements – The petitioners believe that participants in this WINGS option must demonstrate the ability to execute “missions” appropriate to their typical operational profile. Pilots without instrument ratings should execute and log at least two cross - country flights within each quarter and pilots with instrument ratings wishing to exercise these privileges should complete at least two flights under instrument flight rules each quarter.  Skill demonstration every two years – Th e petitioners recognize the importance of basic flight skills and the fact that these skills may deteriorate over time. We believe that this4

deterioration level is reduced for active pilots and that a skill demonstration every two years, rather than three hours of instruction every year as required by the current WINGS program, is sufficient for participants in the proposed new WINGS option. This skill demonstration should be standardized for both VFR and IFR options. Instructors authorized to conduct this skill demonstration should be standardized, perhaps thro ugh the cooperation of training organizations as repre sented by co - petitioner Bonanza Pilot Training, Inc. Poor risk management is a root cause of most general aviation fatal accidents The petitioners believe that general aviation currency and training requirements should be directed at mitigating primary fatal accident causes. A key assertion in co - petitioner Robert Wright’s attached paper is that the general aviation fatal accident rate has been fla t for the last ten or more years. In fact, National Transportation Safety Board (NTSB) data indicate that the fatal accident rate for personal general aviation has been steadily increasing over the last decade. Co - petitioner Robert Wright’s analysis in th e attached paper indicates that the root cause of from 70 - 75 per cent of general aviation fatal accidents is due to poor risk management by the pilot. That is, the pilot failed to identify, assess, and/or mitigate known risks for the accident flight. The c o - petitioner’s analysis in the paper asserts that the current pilot training doctrine, testing standards, curriculum, and flight instruction do not adequately train and test pilots to conduct risk ma nagement. Furthermore, there is no requirement for risk m anagement training in the flight review required by Section 61.56(c) and the aeronautical decision - making ( ADM ) requirement in the current WINGS program is insufficient . Thus, current training requirements require little risk management emphasis in either initial training or during recurrent training for most general aviation pilots. Neither the WINGS program nor the flight review adequately addresses risk management The W INGS program requires that participants successfully complete three knowledge “credits” and three skill “credits” to meet the completion requirements for the program in order for it to substitute for the flight review. In 2012, the FAA added a requirement that one knowledge credit must be fro m a defined list of ADM courses . Risk management is a skill related to ADM but, in the opinion of the petitioners, not all of the ADM training offered in the WINGS program fully covers essential risk management skills. These skill elements include basic risk management principles; ris k identification, assessment, and mitigation procedures; accident examples and illustrations; a relevant case study; and, a final examination. Petitioner Robert Wright completed the three co urses specified as options for the mandatory ADM element. In his view, all of them offered some of the elements of the risk management content specified above, but none of them offered all of the elements listed. The petitioners also believe that the WING S program flight credit elements do not adequately emphasize risk management. The three credit requirements are ma neuvers- based and emphasize elementary flight and training maneuvers. This may be appropriate for pilots with low total flight time or for pil ots who fly infrequently, but may not address more important5

skills that experienced pilots need for cross country or flights in actual instrument conditions in the National Airspace System (NAS). The petitioners believe that more emphasis is needed on ris k management and other single pilot resource management (SRM) skills during the skill portion of the WINGS program. The risk management and SRM skills should be demonstrated as part of a scenario - based flight rather than a solely maneuver- based flight. The petitioners believe that maneuver based skills deteriorate very slowly for experienced pilots who fly frequently and that the interval between required dual instruction can be extended providing such pilots are proficient in risk management and other SRM techniques. The WINGS program needs better incentives for active pilots The petitioners believe that the current WINGS program is still an improvement over the flight review. However, only a small percentage of pilots take WINGS approved training and an even smaller number complete the entire program such that it will substitute for the flight review. For example, information provided to petitioner Robert Wright by the FAA Safety Team that manages the WINGS program indicates that about 100,000 pilots out of about 600,000 have completed at least some element of the WINGS program, but as of November 2012 only about 15,000 pilots have successfully completed the WINGS program at some level. This is only about 2.5 per cent of the U.S. pilot population. Clearly, it would be in the FAA’s and aviation community’s interest to incentivize participation in the WINGS program. An FAA study revealed that while about 2.5 per cent of pilots have completed a WINGS program, they are involved in less than one per cent of acci dents. One obstacle is that considerably more participant time and cost is required to complete a WINGS program phase than is required to complete a flight review. Flight reviews require a minimum of two hours of flight instructor time and one hour of airc raft time every two years. The WINGS program requires from 3 - 6 hours of ground instruction and/or class time (alt hough this is often at no cost), three hours of flight instructor time, and three hours of airplane time. If the interval for training was exte nded for more experienced pilots, the n significantly less time and cost would be incurred by the participants even if mandatory annual risk management training were required . This incentive could greatly increase WINGS program participation if it was adequ ately promoted by FAA and the aviation community. The new WINGS option should be marketed differently The petitioners envision that the new WINGS option could be designated as **“PRO WINGS: The proficiency program for active pilots.”**  The petiti oners further envision that PRO WINGS participants would begin their involvement with a comprehensive risk management knowledge initial course and a scenario - based skill flight with an authorized flight instructor that mirrors the applicant’s typical “mission” profile. The skill demonstration and follow- on activity levels should be tailored to either visual or instrument flight rules to match the participant’s typical mission profile. To remain enrolled, participant s would have to meet continuing activity levels and comp lete an annual risk management knowledge refresher course. At the two year point, they must again complete a scenario - based skill flight with an instructor.6

The petitioners suggest that FAA may wish to develop PRO WINGS in collaboration with specific general aviation organizations that have an interest in flight operations tailored to the PRO WINGS philosophy. This could include individual aircraft type specific organizat ions, such as the co - petitioner representing Beech aircraft models. The FAA may even wi sh to consider the feasibility of tailoring PRO WINGS programs to individual aircraft constituencies or other affiliations. This would enhance the image that PRO WINGS is not a “one size fits all” program such as the current WINGS program. The petitioners have included some proposed program elements in Appendi x 4 of the attachment. T he petitioners suggest that FAA and the aviation community collaborate to analyze accident and other data to establish program parameters and create detailed content and partici pation procedures. The petitioners are willing to advise and assist with this effort. The FAA may also wish to conduct a demonstration program to validate the assertions in this petition and compare the results with current general aviation recurrent train in g requirements . Bonanza Proficiency Training, Inc. is willing to serve as a vehicle for conducting such a “beta” test. The new WINGS option should include both generic and “type club” options The FAA should create a generic PRO WINGS option that applies to typical general aviation pilots who are not necessarily affiliated with particular aircraft models or “type clubs” and owner organizations that represent owners of these aircraft models. In addition, the FAA should create, at the request of individual type clubs and owner organizations, PRO WINGS programs which address the safety issues, operating problems, and use profiles of particular aircraft models. By creating both generic and type club specific PRO WINGS options, the FAA would maximize the number of general aviation pilots that would desire to participate in PRO WINGS. Additionally, FAA would be leveraging its own scarce resources by enlisting the support, promotional, and outreach resources of aircraft type clubs. **Public benefits and interests as** **sociated with request:** The public benefits and interests, other than safety, that would accrue from implementing the recommendations in this petition relate to cost savings for both the government and general aviation pilot. The government would financiall y benefit from the proposal because of the tremendous resource leveraging inherent in the activities of the FAA Safety Team. Very few FAA Flight Standards inspectors are assigned to this program because the aviation community provides most of the resources and implementation, including training course development and delivery. Any expansion of the WINGS program that effectively reduces accidents results in enhanced mi ssion accomplishment with minimal or no additional FAA resources. Furthermore, any reduction in accidents could also reduce both FAA and NTSB costs that would be incurred in investigating accidents and conducting enforcement actions.7

The general aviation community would also accrue cost and participant time savings if they participated in the PRO WINGS option. For example, a pilot in the current WINGS program could require about four hours of time for knowledge training and three hours of aircraft and inst ructor time annually . Over a four year period this could cost 28 hours of participant time and 12 hours of instructor and airplane time. A PRO WINGS participant, on the othe r hand, would require perhaps nine h ours of participant time and three hours of instructor and airplane time in that four year period. At $30 value of time per hour for the participant and $150 per hour for airplane instruction a conventional WINGS program would cost the participant roughly $2700 during those four years while the P RO WIN GS program might cost roughly $800 . This is a savings of about $1900 or nearly $500 per year. If 30,000 pilots enrolled in PRO WINGS this might amount to annual public benefits of $15,000,000. The petitioners assume that the higher activity levels required to participate in the PRO WINGS option are already justified by the participant’s use of the airplane for other purposes, such as transportation or recreation. In other words, most participants aren’t flying more just to participate in PRO WINGS, but rath er already fly more for other personal or business reasons. **Impact of request on general aviation safety:** The petitioners believe that the Pro WINGS program could significantly reduce fatal accidents. Since the root cause of about 70 - 75 per cent of fatal a ccidents is poor risk management, any program that emphasizes effective risk management could directly impact this record. The FAA in recent years has required air carriers to implement crew resource management (CRM) training and this has significantly imp roved air carrier safety. Concepts such as threat and error management (TEM) are a part of this emphasis. The equivalent program for single - pilot general aviation crews is SR M and risk management training. The petitioners also note that the FAA has forme d an Aviation Rulemaking Advisory Committee (ARAC) group to address pilot training issues. The Airman Testing Standards and Training Working Group was tasked in September 2012 to recommend ways to ensure that the FAA’s airman testing and training materials better support reduction of fatal general aviation accidents (see Federal Register notice, Vol. 77, no. 177, September 12, 2012, pp. 56251 - 56253). The notice stated that “...the Working Group should follow the ARC’s [previous] recommendations to integrate a ppropriate elements of aeronautical knowledge and risk management [emphasis added] into each Area of Operation in the current Practical Test Standards documents.” The petitioners also note that at FAA and industry group has proposed that Airman Certificati on Standards (ACS) would replace the Practical Test Standards (PTS) for pilot certifications and that the ACS would specifically include risk management skill demonstration as a component of ACS tasks and objectives. The petitioners conclude that FAA’s in tent is to follow through on industry recommendations to emphasize risk management as a critical pilot skill because it will potentially reduce the fatal accident rate. The petitioners thus believe that our proposal will not have an adverse impact on general aviation safety but rather is likely to greatly reduce fatal and non -fatal accidents. The data in the attached analysis conducted by petitioner Robert Wright supports this assertion.8

**Summary of proposal for Federal Register publication:**  The petitioners request that the FAA amend Advisory Circular 61 - 91J to permit a new WINGS Pilot Proficiency Program option for experienced pilots. This option would require annual risk management knowledge training becaus e the petitioners believe that poor risk management is the root cause of between 70- 75 per cent of general aviation fatal accidents. If pilots enrolled in this WINGS option meet certain activity levels and demonstrate continued safe operation, their interv al for required dual instruction could be extend ed to either two years . The petitioners believe that if significant numbers of pilots participated in this WINGS option and then practiced effective risk management techniques, then it could significantly red uce the general aviation fatal accident rate. **Date submitted:** January 25, 2014 **Supporting documentation:** In support of this petition, we submit the following analysis, prepared by co - petitioner Robert Wrigh t in May 2013, and revised in July 2013. (Analysis begins on next page)9



## An Analysis of Poor Risk Management as a Major Determinant of **General Aviation Fatal Accident Root Causality: Some Pilot Training Implications** 

Robert A. Wright Wright Aviation Solutions LLC flyrawright@yahoo.com

May 2012 (Revised July 2013)

The contents, analysis, conclusions, and recommendations in this document are the exclusive property of Wright Aviation Solutions LLC. They may not be quoted, cited, or attributed without the express written consent of the author.10 

### Contents I. Introduction, Purpose, and Synopsis II. Disclosures III. Background IV. Scope and Methodology V. Analysis of Fatal Accident Causality in Test Populations VI. Pilot Training Issues Related to F atal Accident Causality VII. Conclusions and Recommendations Appendix 1 – List of Cirrus fatal accidents analyzed Appendix 2 – List of Cessna 172, Cirrus, and Beech Bonanza fatal accidents analyzed Appendix 3 – List of Arizona fatal accidents analyzed Appendix 4 – Proposed Enhanced FAA Pilot Proficiency Program Appendix 5 – Proposed Minimum Standards for Initial and Recurrent Risk Management Training Appendix 6 – References11



### I. **Introduction, Purpose, and Synopsis** This paper discusses issues relating to the root causes of general aviation fatal accidents. It includes the author’s analysis of three small populations of general aviation fatal accidents which occurred during the period 2001 - 2010. Each population studied represents a different group of aircraft makes and models or a specific geographic area. Each analysis was conducted independent of the other and was accomplished for a different purpose. These purposes included work on behalf of clients, preparation for articles, and preparation for presentations. It is the author’s thesis that an overwhelming percentage of general aviation fatal accidents occur because the pilot used poor risk management techniques or did not use any risk management procedures at all. That is, the pilot failed to identify, assess, an d/or mitigate known hazards and risks to a proposed or ongoing flight. The specified probable causes and other factors for these accidents, as specified in National Transportation Safety Board (NTSB) accident reports and other documents, do not reveal ris k management as a root cause because these reports only specify the proximate cause or final event that led to the accident, and occasionally related “causal” factors. The analysis performed by the author and discussed in this paper validates the author’s thesis. In the samples analyzed, between two thirds and three fourths of the fatal accidents exhibited factors that characterize them as risk management accidents. That is, the pilots failed to identify, assess, and/or mitigate known hazards and risks. In the author’s opinion, if the pilot had performed these tasks it is likely that these accidents would not have occurred. The author believes that poor risk management dominates the root causality of general aviation fatal accidents because risk management i s not effectively taught in general aviation training activities. Up -to - date doctrine on risk management has only been available from the Federal Aviation Administration (FAA) since 2009. Testing standards for the knowledge and practical tests have only be en recently revised to include risk management skills and these revisions may not effectively test for these skills. As a result, initial training curricula, flight reviews, and other training activity generally does not effectively teach or evaluate risk management knowledge and skills. The author recommends changes to FAA doctrine, standards, flight instructor guidance and standardization, pilot examiner standardization, flight review guidance, and the FAA Wings Program. He also recommends changes in NTSB accident investigation taxonomy. These changes should be accompanied by collaborative actions by the aviation community, including industry training and courseware providers.12



### II. **Disclosures** The author of this paper, Robert A. Wright, is a well - known aviatio n safety consultant and subject matter expert. His consultant practice includes clients such as aircraft manufacturers, aviation training companies, investment companies, and other entities. Mr. Wright began his practice in 2005, following his retirement a s an FAA executive. He completed a twenty two year career with the FAA, following twelve years with the U.S. Air Force and the Government Accountability Office (GAO). In his final FAA position, from 2001 to 2005, Mr. Wright was Manager of the General Aviat ion and Commercial Division (AFS - 800) in FAA headquarters. In this position, he was responsible for all FAA policy and regulation relating to general aviation pilot training. From 2003 to 2005, Mr. Wright created and implemented the FAA Industry Training Standards (FITS) program. This program was designed to begin modernization of pilot training with an emphasis on scenario based training and higher order pilot skills such as risk management. Mr. Wright’s aviation background includes industry experience before and after his Federal service. This includes experience as an air taxi and ferry pilot, flight instructor, and other positions. From 2005 to 2008, he was Director of Flight Training and then Director of Regulatory Affairs for Eclipse Aviation in Albuqu erque, NM. In this role, he designed and implemented the single - pilot training program for the Eclipse 500 very light jet. Mr. Wright holds Airline Transport Pilot and Flight Instructor Certificates and has more than 9400 flight hours. Mr. Wright is curren tly participating in a venture to develop single pilot resource management (SRM) training for pilots of light business aircraft. He also writes articles for Aviation Safety magazine on risk management and related subjects. Mr. Wright led an effort to devel op and conduct a Pilot Training Reform Symposium that was sponsored and held by the Society of Aviation and Flight Educators (SAFE) in Atlanta, GA in May 2011. He received the SAFE Founders Award that year for his efforts. Although Mr. Wright is a member of SAFE, he holds no position as an officer in that organization. Mr. Wright was not commissioned by any client, company, or other entity to produce this paper and he prepared it on his own initiative and with his own resources. The opinions he expresses do not necessarily represent the positions of any client, organization, or other person. The author prepared this paper to document his research on general aviation fatal accident causality and the relationship of these accidents to risk management and gener al aviation pilot training. In this manner, he hopes to influence development of FAA and industry programs to reduce the number of these accidents.13



### III. **Background** The general aviation fatal accident rate stagnated during the period 2001 - 2010. It remained essen tially unchanged at 1.27 fatal accidents per 100,000 flight hours in both 2001 and 2010 according to NTSB data. This stagnation follows a long period of several decades in which the fatal accident rate slowly but steadily declined. During this same period, air carrier major accident rates decreased from .0281 to .0057 per 100,000 flight hours, about an 80 per cent decrease. Much of this improvement in commercial aviation safety has been attributed to the activities of the Commercial Aviation Safety Team (CAST). The CAST is a collaborative government/industry effort to identify accident root causes and develop mitigations to address these factors. It was founded in 1998 and continues to operate. An equivalent organization to address general aviation fatal acc idents, the General Aviation Joint Steering Committee (GAJSC) was also created in 1998. The JSC, like the CAST, evaluated accidents and devised mitigations to reduce future general aviation accidents. The fact that the general aviation accident rate has not declined, despite the efforts of the GAJSC, is probably the result of a number of factors. Some of these factors, such as the diverse nature of general aviation flight operations, are beyond the scope of the GAJSC to influence. We should, however, consid er the methodology used by the GAJSC to identify accident root causality. Like the CAST, the GAJSC analyzed and ranked leading accident causes. The GAJSC found that loss of control, weather, and controlled flight into terrain were the leading causes of accidents cited in NTSB fatal accident reports. The GAJSC elected to design mitigations for these accident causes but may have insufficiently evaluated the root causality of these accidents. For example, for loss of control accidents, it is imperative to d etermine “why” the pilot lost control, not just “how, when, where, and who” lost control of the aircraft. For example, some loss of control accidents occurred because non - instrument rated pilots attempted continued visual flight rules (VFR) operations into instrument meteorological conditions (IMC). The true root cause of such an accident could be poor risk management by the pilot, rather than an inability to control the aircraft solely by instruments. The FAA Industry Training Standards (FITS) program was created by FAA in 2003 to explore the connection between general aviation fatal accidents, higher order pilot skills such as risk management, and the general aviation training system. The program included industry and academia, as well as FAA. The FITS program also explored modernized teaching and learning methods, such as scenario - based training and student - centered learning and grading.14

Another element of the FITS program examined the impact of new flight technologies available in emerging technically ad vanced aircraft (TAA). In a 2003 study, an industry/FAA team found that, while TAA aircraft could provide increased “available safety”, this improvement could only occur if pilots in these aircraft received additional training in the specific TAA systems that would enable them to exploit the benefits of the technology while recognizing its limitations. An NTSB study completed in 2011 found that the fatal accident rate of recently introduced TAA was worse than that of legacy general aviation aircraft with conventional instrumentation (i.e. “steam gauges”). The NTSB report noted deficiencies in FAA training and testing standards, among other issues. The author believes that automation, and automation management, is an important issue and determinant of gene ral aviation safety results. He also believes, however, that other higher order pilot skills such as risk management may be of even greater influence in general aviation safety outcomes. The author has previously noted the importance of higher level pilot skills in a paper that he published in 2003 through the American Institute of Aeronautics and Astronautics (AIAA). This paper outlined the elements of the FITS program that was initiated by FAA in that year under the author’s leadership. In the following two years, and during client and other consulting, publishing, and research following his retirement from FAA, the author noted empirical data concerning the prevalence of poor risk management in general aviation fatal accidents. He decided to develop this paper to provide this data to a wider audience within FAA, NTSB, and the aviation community. The primary empirical data supporting the author’s thesis that poor risk management is the root cause of most general aviation fatal accidents is crucial to understanding how FAA and the community can devise mitigations to address this fact and ultimately reduce the fatal accident rate. The author describes his methodology for demonstrating that poor risk management is the root cause of these accidents in Section IV, Scope and Methodology. The actual results obtained from analyzing three small populations of general aviation fatal accidents are discussed in Section V, Analysis of Fatal Accident Causality in Test Populations. The author notes that his analysis is limi ted to personal general aviation fatal accidents and excludes commercial activity and experimental aircraft. While his results, conclusions, and recommendations address issues related to fatal accidents, he also believes that poor risk management plays a s ignificant role in these other populations as well as in non -fatal general aviation accidents.15



### IV. **Scope and Methodology** The data developed by the author to demonstrate the preponderance of poor risk management as a root cause of general aviation fatal accide nts is based on an analysis of NTSB accident reports on individual accidents. These NTSB reports included the Preliminary Narrative (Form 6120.19), Final Narrative (Form 6120.4), and Probable Cause Narrative. The author selected all reports for a given pop ulation of accidents designed to support the information needs of a client, a journal article, and a presentation for a seminar. These three populations totaled 37, 68, and 53 accidents, respectively. Since these three populations intersected, they totaled 150 accidents, rather than 158, excluding eight accidents that appeared on more than one sample. The accidents were not chosen randomly and the author arbitrarily selected recent time periods tailored to the needs of the client, article, and presentation . The author selected all accidents for analysis within the selected time period. Despite these limitations in the sample, the populations were representative of diverse general aviation aircraft models, geographic and environmental conditions, and pilot e xperience. The author’s objective was to “test” each accident to determine whether or not it could be declared a risk management accident, from the point of view of its root cause. The author was seeking information from the NTSB documents to determine if there was a readily identifiable hazard to each flight that presented a high level of risk and was detectable by the pilot before the flight and/or during the flight as it progressed. The author then applied the following multi

part test to determine if th e accident could be declared a risk management accident.

 If the pilot could have identified hazards that could have created unacceptable risk to the proposed or ongoing flight using the common PAVE (Pilot, Aircraft, Environment, External Pressures) checkli st for risk identification , and

 If the pilot could have assessed the risk in terms of likelihood and severity such that high (“red”) or moderate (“yellow”) risks would be apparent, and

 If the pilot had taken effective steps to mitigate, i.e. reduce likelih ood and/or severity of the risk, then

 Could the accident been avoided? The author hypothesizes that if all of these questions are “positive”, then the accident may be termed a risk management accident from the point of view of its root cause. If any of the test elements are negative then the accident cannot be labeled as a ri sk management accident.16

For example, if the hazard was undetectable to the pilot, such as an unexpected engine failure in an otherwise well - maintained engine, than the pilot could not have consciously identified, assessed, and then mitigated the risk before the event occurred. The author notes that if the hazard/risk can be identified by the pilot, it is highly likely that the pilot can also assess its likelihood and severity and take action to mitigate it. In determining the relative degree of risk of read ily visible hazards identified in the NTSB reports, the author evaluated the severity and likelihood of each hazard/risk using levels described in the FAA Risk Management Handbook. He then applied these levels to each risk using the risk assessment matrix described in the FAA handbook. In this manner, the author could evaluate the overall level of risk. The doctrine in the FAA handbook suggests that all “high” levels of risk must be mitigated by the pilot before departure or before continuing an ongoing fli ght. The handbook also recommends mitigation of “moderate” risks. Finally, the author considered what kind of mitigation the pilot may have employed to reduce the likelihood or severity of the risk. However, this analysis is not crucial to determining whet her the accident’s root cause was poor risk management, unless it would have been impossible for the pilot to take effective mitigating action(s). The final determinations on risk for each accident are contained in Appendices 1, 2, and 3. Each accident is listed by date and NTSB case number. The author’s detailed data and analysis on each accident is contained in his work papers that are not part of this report. The author invites interested parties to retrieve the NTSB reports if they wish to make their ow n independent assessment of the accidents listed. The author recognizes that the process for determining whether risk management played a role in the accident is somewhat subjective. However, he also believes that the multi - part test described above is con servative and rigorous enough to give him confidence in his final conclusions about individual accidents and to then make informed deductive recommendations.17



### V. **Analysis of Fatal Accident Causality in Test Populations** The author’s analysis of the prevalence of poor risk management in general aviation fatal accidents is supported by data and his resulting analysis from the following three populations of general aviation fatal accidents.

 37 fatal accidents in Cirrus aircraft occurring between 1999 an d May 1, 2008; analyzed by the author as preliminary work prior to a client engagement. These accidents are listed in Appendix 1 .

 68 fatal accidents of Cirrus SR22, Beech Bonanza V35, and Cessna 172 aircraft that occurred from 2007 through 2009; analyzed by the author to support an article on risk management for the March 2012 issue of Aviation Safety magazine. These accidents are listed in Appendix 2 .

 53 fatal accidents occurring in Arizona from 2001 through 2010; analyzed by the author to support a pres entation on risk management to the Arizona Pilots Association in March 2012. These accidents are listed in Appendix 3 . Since Cirrus accidents occurred in all three of these populations, the total number of accidents analyzed was 150, rather than 158. The following data summarizes the results obtained by the author, using the methodology described in Section IV, to determine the extent that poor risk management was the root cause of these accidents. Analysis of 37 Cirrus fatal accidents All available Cirru s accidents in the data base for the selected period were examined. Of the 37 accidents, the author excluded six that were either special category non - personal use accidents (such as factory flight test or oceanic ferry flights) or had insufficient data in the NTSB documents to make a determination. For the remaining 31 accidents the author concluded that 22 (71 per cent) were risk management accidents. For this accident population and client engagement, the author was also looking for evidence that other h igher order pilot skills comprising SRM, such as automation management and task and workload management, were also a component of the root causality of these accidents. The author concluded that five (16 per cent) of the 31 accidents had root causes involv ing multiple SRM skill deficiencies of the pilot. Only four (13 per cent) of the accidents could be attributed to poor conventional physical skills by the pilot. None of the 31 accidents appeared to have root causes that were not pilot - related (aircraft, etc.).18

Analysis of 68 Cirrus SR22, Beech Bonanza V35, and Cessna 172 fatal accidents To research an article on risk management, the author wanted to determine if the prevalence of risk management accidents varied significantly depending on the complexity an d performance of the aircraft. Accordingly, for analysis he selected the Cirrus SR22, a high performance TAA aircraft; the Beech Bonanza V35, a legacy high performance complex aircraft (most with conventional instruments); and the Cessna 172, a simple fixe d gear personal aircraft. The results of this analysis demonstrate that poor risk management is prevalent as a root cause of fatal accidents regardless of the aircraft type. Of the 68 accidents, 18 were excluded because of insufficient data for analysis. Most of these 18 accidents happened outside the United States. Of the remaining 50 accidents with sufficient data, the author concluded that 39 (78 per cent) could be attributed to poor risk management as a root cause. This included seven (70 per cent) of the 10 Cirrus accidents, eight (67 per cent) of the 12 Bonanza accidents, and a surprising 24 (86 per cent) of the 28 Cessna 172 fatal accidents. Prior to this analysis, the author would have expected the Cessna 172 to have a smaller percentage of risk m anagement and a higher percentage of physical skills related accidents. Possibly the easy to fly and slow speed characteristics of the Cessna and the relative inexperience of the pilots resulted in a higher percentage of risk management accidents. Of the 1 1 accidents that the author concluded were not based on poor risk management, nine were judged to be based on inadequate physical flying skills and two were aircraft related. Inadvertent stalls and improper stall recovery accounted for five of the nine ski ll accidents, with three of those occurring in the Cessna 172 sample. In this analysis, the author also analyzed the 39 risk management accidents to determine the predominant origin of the hazard that created the risk, using the well - known **PAVE** (Pilot, Aircraft, Environment, External Pressures) checklist. Some accidents had multiple hazards that created the risk that likely resulted in the accident. Of 62 major factors identified, environmental hazards/risks accounted for 34 (55 per cent). Numerous types of environmental hazards were noted, including weather, terrain, other aircraft, and density altitude. Pilot qualification - related hazards and risks include both basic qualification and aero medical qualification and were the next highest PAVE - related catego ry. The author noted that pilot qualification - related risks accounted for 23 (37 per cent) of the risks identified. The remaining five PAVE factors were due to known aircraft issues and external pressures. The author notes that external pressure - related ha zards may be more numerous and are difficult to authoritatively detect in NTSB accident reports.19

Analysis of 53 Arizona fatal accidents To prepare for a presentation to the Arizona Pilots Association, the author wished to focus on Arizona personal fatal ac cidents during a ten year period from 2001 through 2010. The data base yielded 53 fatal accidents in this period. Of these, seven had insufficient data for analysis and the author evaluated the remaining 46 using the same methodology as the previous two po pulations discussed. Of the 46 fatal accidents, the author concluded that 35 (76 per cent) had poor risk management as a root cause. Of the remaining 11 accidents, seven were aircraft- related (including six unexpected engine failures). The other four were judged to be due to inadequate physical pilot skills. As with the analysis of different make and models in the previous section, the author evaluated the origin of the hazards/risks that he concluded was the basis for the risk management accident. He note d 53 **PAVE** risk factors for the 46 accidents. Of these 32 (60 per cent) were environmental and included the same hazards as mentioned in the previous sample. Density altitude accidents were especially prominent, as might be expected in Arizona, and weather hazards were also prominent. Pilot qualification - related hazards occurred in 12 (23 per cent) of the 53 PAVE factors. The remaining nine factors were about evenly split between aircraft and external pressure hazards/risks. Summary of Root Cause Analysis o f Three Fatal Accident Groups Of the 158 accident files analyzed by the author, this represents 150 actual accidents, when the duplicate Cirrus files were excluded. Of these, 30 accidents could not be evaluated because there was insufficient data to make a n informed decision about whether poor risk management was a root cause, or not. Of the 120 accidents with sufficient data, the author concluded that the root cause of 90 (75 per cent) was poor risk management by the pilot. The author notes that the percentage of risk management accidents for each population was remarkably consistent and he believes that, despite the small sample size and lack of random selection, this figure is probably close to the actual figure for all personal use general aviation fatal accidents in non - experimental aircraft. Additional research is needed to determine how the percentage of risk management accidents varies for non -fatal accidents, for pilots of varying experience levels, and for other variables. The author believes that the percentage of accidents with root causes related to poor risk management is likely high for most sub -groups.20



### VI. **Pilot Training Issues Related to Fatal Accident Causality** The data in the previous section suggests the prominence of poor risk management as the root cause of a solid majority of general aviation fatal accidents. The author, in his analyses described in Section V, was careful to only describe an accident as a risk management accident if the hazards/risks were known to the pilot or should ha ve been known to the pilot if he/she was using effective risk management procedures. This leads us to ask the question: why did the pilot fail to take action in the face of known risks or why did the pilot fail to use proper risk management procedures? The author suggests that the following six reasons may explain this. 1. Lack of risk management training 2. Failure to continuously apply risk management as the flight progresses 3. Inaccurate assessment of risk and/or failure to mitigate medium and high risks 4. A desire for greater utility, especially when enabled by advanced technology 5. A higher tolerance of risk than is wise 6. Intentional disregard for high risks The author believes that the last two factors are cultural in nature and are especially difficult to address, given the current and past history of general aviation. These factors are abetted by leadership in the community that chooses to ignore risk issues for a variety of reasons related to marketing and other factors. It is beyond the scope of this paper to ad dress these cultural issues. The author suggests that it would require action by FAA leadership and the community leadership to address them. The previous FAA Administrator touched on this subject by emphasizing professionalism, but a broader treatment of the problem is needed. The author believes that the first four reasons listed above are directly related to the general aviation pilot and flight instructor initial and recurrent training requirements and the system for ensuring the effectiveness of those requirements. As discussed in Section III, the research conducted under the FITS program enabled FAA to begin updating the elements of the general aviation training system to address required changes. The training system includes the following elements.

 Doctrine – This includes official FAA handbooks and other doctrine material, as well as some industry guidance material. Doctrine covers the “what” and “why” of flight training elements and procedures.  Standards – These include the knowledge tests and pract ical test standards (PTS). They effectively set the completion standard for training and what actually gets taught by instructors and training providers.21

 Curricula – This element covers the “when, where, and how” of flight instruction. It includes syllabi, simulation and other training tools, and the methods for delivering training.  Instruction – This element represents the “who” of flight instruction. It includes flight and ground instructors, pilot schools, training centers, courseware providers, and othe r entities. Current status of training reform and modernization The process of modernizing the training system begun by FITS is incomplete. The doctrine has been updated and continues to evolve, but this process may not be fully mature. For example, in 200 9 FAA published a Risk Management Handbook but it may not completely cover all elements of practical risk management, such as risk mitigation or use of risk mitigation tools. Standards are slowly being updated to reflect FITS concepts as well as other need ed changes. An aviation rulemaking advisory committee (ARAC) chartered to review the knowledge tests completed its work and transmitted its report to FAA in April 2012. The report contained nine recommendations for improving knowledge tests in the areas of industry participation in test development, test quality and content, and other areas. Significantly, risk management was added as a specific competency that must be tested for each pilot certificate. The ARAC also recommended a single testing standard that would incorporate the current PTS system. Meanwhile, the FAA continues to update the current PTS system to incorporate a requirement for single pilot resource management (SRM) knowledge and skill. This includes risk management knowledge and skills. Th e FAA initiated this requirement in the instrument rating PTS in 2010 and in 2012 the private pilot and commercial pilot PTS were similarly revised. However, the SRM testing requirement is separated from the main body of tasks and objectives in these PTS d ocuments. For example, the tasks and objectives for pre -flight planning do not include a requirement for the pilot to demonstrate that he/she can perform a risk analysis as part of the preflight planning. The separation of the SRM and risk management tasks and objectives from the main body of the PTS raises questions regarding whether or not flight instructor are preparing students to accomplish these tasks and whether or not pilot examiners are testing for these skills on practical tests. These questions a re crucial since the current curricula in industry are designed to prepare students to pass knowledge and practical tests rather than prepare them to operate in the real world in high performance TAA. The GAJSC has also recently increased its efforts to a nalyze general aviation accidents and this has resulted in pending recommendations for incorporating risk management and other22

higher order pilot skills in general aviation training. As the author was completing this paper, the GAJSC Loss of Control Work G roup issued recommendations to the FAA, including twenty detailed implementation plans (DIP) with forty safety enhancements (SE). Three of the DIP, containing five SE, target risk management and related issues including Risk Based Flight Review, Single - Pil ot CRM (i.e. SRM), and Aeronautical Decision Making (ADM). Delivery of modernized training Since the issuance of comprehensive training doctrine and standards reflecting FITS concepts was really only begun about five years ago, most industry training curri cula still do not reflect modernized doctrine and standards. Furthermore, unless and until flight instructors, pilot schools, training centers, pilot examiners, and FAA inspectors are trained and standardized in the use of FITS concepts and methods, it is unlikely that real progress in training reform will occur and consequently the new concepts will not have any impact on fatal accident rates. Some innovation and training reform is being conducted on a small scale by some training providers and courseware producers. One promising initiative is being conducted by a partnership including Redbird Simulations, Cessna Aircraft, and King Schools. This initiative seeks to produce and deliver an integrated training program with expanded on - line training, maximum si mulation use, and scenario training. This program also incorporates risk management training from day one in the training program. High end general aviation training, including type rating and recurrent training, also needs to reflect modernized training c oncepts. Most of this training occurs in Part 142 training centers and is simulator based. Some members of the business aviation community have criticized the training center industry, stating that too much of the training is maneuvers - based, rather than s cenario - based, and it does not address higher order pilot skills such as CRM/SRM and risk management. For aircraft requiring a type rating, such as the Cessna Citation, this training is driven by the proficiency check required by Section 61.58. For non -typ e rated aircraft, however, the training center specifications and curricula can be readily changed by the training centers with FAA approval. This flexibility inherent in the Part 142 regulation has probably been hampered by FAA policies contained in hand books and other non - regulatory guidance material. The FAA can change these policies without regulatory initiatives. The author believes that FAA should do so and push the training centers to produce and deliver more training emphasizing scenarios, higher o rder pilot skills such as risk management, and using delivery methods such as on - line training. The business aviation community, including training providers and courseware providers who do not hold training center certificates, would be willing partners i n this effort.23

Training issues for pilots already certificated Even if the initial pilot training system was fully modernized and reformed to embrace FITS, it initially would only affect new pilot starts and added ratings. This would affect the 50,000 or so new student starts each year and the 15,000 or so new private pilot certificates issued, but it would not affect the 500,000+ pilots who are already certificated. The only way to reach these pilots and provide them with risk management training is throu gh current mandatory recurrent training events. Essentially, most general aviation pilots have three options for fulfilling this requirement under current regulations.

 Complete a flight review once every two years, as specified in Section 61.56(a) or (b)  C omplete an FAA sponsored pilot proficiency program annually as specified in Section 61.56(e)  Complete a new certificate, rating, or pilot proficiency check as specified in Section 61.56(d) The flight review has essentially no completion standards and the i nstructor has full discretion in terms of what to cover on the review. Typically, these reviews are maneuverbased with no emphasis on risk management or other higher order pilot skills. This is also typically true regarding proficiency checks and practica l tests. The pilot proficiency program, generally known as the “Wings” program, has more extensive requirements than the flight review. These are outlined in the Advisory Circular (AC) 61 - 91J, most recently revised in 2011, and on the www.faasafety.gov web site that is operated by the FAA Safety Team (FAAST Team). To serve as an alternate to the flight review, the Wings program generally requires a pilot to complete three knowledge “credits” and three flight activity “credits” each year. Three levels of consecutive achievement are recognized: Basic, Advanced, and Master. Risk management is only listed as an option for one of the three knowledge requirements, and it is only listed at the Basic level. As with all knowle dge subjects, there is little or no content control over what is covered. The flight activities “credit” requirements emphasize maneuver- based training in three areas: takeoffs, landings, and go - arounds; slow flight, stalls, and basic instruments; and airp ort operations. The PTS specifies the completion standards and there is no requirement that the pilot demonstrate proficiency in any element of risk management. The FAA guidance material emphasizes that pilots must meet completion standards. The guidance a cknowledges that this occurs for on - line knowledge training, but does not typically occur at “live” Wings seminars and events. The author concludes that, without a specific risk24

management requirement, content control, and effective testing of comprehensio n, risk management knowledge training is not effectively taught in the Wings program. Another issue regarding the Wings program is that it is an optional way to comply with the flight review requirement. Since the requirements for Wings are more rigorous t han a basic flight review, most pilots probably complete the two hours of required instruction for the flight review every two years rather than the approximately six hours required annually for the Wings program. **Given this situation, the author conclude s that neither the flight review nor the Wings**  **program effectively cover risk manageme nt issues and procedures, yet**  **as previously noted perhaps three fourths of personal general aviation accidents have root causes related to poor**  **risk management.** To rectify this situation, FAA and industry need to change both the content and nature of the flight review and the Wings program. It is unlikely that this could be done either successfully or in a timely manner with new regulations. A more effective route wo uld be through incentives, flight instructor standardization, a new option for the Wings program, and standardized and controlled content of risk management training. It is important to note that none of the following actions would require changing the reg ulations but instead could be accomplished through new or revised advisory guidance. Incentives – In order to get more pilots to take risk management training in the Wings program, or seek such training during the flight review, the FAA needs to provide an incentive. The author suggests that this might be based on pilot experience levels. For example, the author boldly suggests that high time pilots, with high hours in type, and who fly many hours in a year, do not need to fly with an instructor annually, e very other year, or even longer periods providing they accumulate enough flight activity “events” to demonstrate a high level of proficiency in their actual operations, as evidenced by continued operation without accidents, incidents, or violations. Of cou rse, at some point all pilots should be subject to a review of basic flight proficiency from an instructor. Even this review should be scenario - based with a demonstration of proper risk management techniques as well as basic flight maneuvers. On the other hand, such experienced pilots might require specific on - line training annually on risk management procedures peculiar to their type of operation and the hazards and risks that he or she is likely to face. The FAA could also administratively issue guidance that risk management training meeting certain criteria could substitute for the review of general operating and flight rules required for the flight review by Section 61.56(a)(1). A risk management course that effectively integrates operating rule issues could easily accomplish this.25

Comparative quality of recurrent training options A new Wings option that included risk management training coupled with annual pilot flight activity requirements is superior to either the flight review or the current Wings program as a means of addressing the general aviation fatal accident rates, in the author’s opinion. Consider first the current requirements. The flight review only requires one hour of ground instruction and one hour of flight instruction every two years. If a pilot maintains the currency needed for continuous passenger carrying privileges during that period he would only need to fly about four hours per year. In the current Wings program, the pilot must complete three knowledge credits and three flight credits each year. Nevertheless, this pilot could maintain continuous passenger carrying privileges by flying only about five hours per year. Wi th either of these options, an instrument rated pilot could exercise passenger carrying privileges in instrument meteorological conditions (IMC) with as little as five hours additional time annually under simulated IMC conditions. These privileges could be exercised without ever having entered a cloud or, perhaps more importantly, ever operated within the air traffic control system under an instrument flight rules flight plan during this period. The author suggests that this level of activity and currency i s insufficient to maintain safe flight operations, even if the pilot complies with the standards set forth in the PTS. The requisite level of knowledge and skill can probably only be maintained at a much higher level of activity. This probably is associate d with some minimum level of total pilot experience, time in aircraft type, and recent flight experience. It probably requires the performance of a certain number of “events” annually to maintain proficiency. The author believes that a new Wings option co uld have two levels of performance beyond the current Wings program. The author suggests that the FAA promote these options as a recurrent training program for general aviation pilots who are very active and associate the program with a higher level of “professional” performance. The FAA could title the program and promote it in this manner. For example, the “sound bite” might be: **“PRO Wings –**  **A currency program for active pilots.”** In order to effectively set the minimum activity levels for “PRO Wings”, th e FAA should examine accident data to determine fatal accident rates at varying levels of total experience, time in aircraft type, and recent flight experience. The author proposes that the program be structured like the example presented in Appendix 4. Th e minimum times and events listed in that table are illustrative, pending a review of additional data.26

Implementation of risk management training The FAA must lead the process of implementing risk management training. Implementation considerations include but are not limited to the following issues. Flight instructor standardization – In order to ensure that risk management training is delivered effectively, FAA needs to standardize how training is accomplished for the flight review. This would require FAA to modify the flight instructor PTS and change the curriculum for flight instructor refresher clinics. New Wings option – As noted above, an incentive - based Wings program option that includes a comprehensive risk management training element is needed to encourage pilots to migrate to this option. The author proposes a specific structure for this Wings option and offers the details in Appendix 4 of this paper. Content of risk management training – In order for risk management training to be effective, its content must be comprehensive with standardized content, it must be consistently delivered, it must include a testing element to measure comprehension, and it must be readily accessible. The author offers more detail support these requirements in Appendix 5 of this paper.27



### VII. **Conclusions and Recommendations** 1. The general aviation fatal accident rate has remained essentially static for more than a decade. Evidence suggests that the root cause of most general aviation fatal accidents is poor risk management. **Recommendation 1:** The FAA and the NTSB, in cooperation with the aviation community, should conduct additional research to validate the root causality of general aviation fatal accidents with respect to poor risk management. This research should be expande d to include non -fatal accidents, as well as the variability of risk management accidents for pilots of varying total flight time, time in type, and recent flight experience, as well as other variables.

2. Pilot training reform has made some progress, but FAA training doctrine such as handbooks have not been completely modernized to reflect all required content. This includes some elements of the risk management process, especially risk mitigation and use of risk management tools. **Recommendation 2:** The FAA, in cooperation with the aviation community, should update FAA doctrine and associated handbooks to add material on the role risk management plays in fatal accidents, the sequential risk management process (i.e. identify, assess, mitigate), risk mitigation and associated techniques, and use of risk management tools. The updated doctrine should be fully reflected in a timely revision of the Risk Management Handbook (FAA- H - 8083 - 2). Supplementary doctrine material, such as that produced by the FAAST Team, shoul d also be updated.

3. Pilot training standards, including the knowledge test and the practical test, have not been fully modernized to reflect required testing of pilot risk management knowledge and skills. The aviation community has recognized the need to incorporate risk management in knowledge testing. The FAA has begun to incorporate SRM and risk management testing in the PTS, but the manner in which it is described may not effectively or consistently enable the examiner to test risk management skills. **R ecommendation 3:**  The FAA, in cooperation with the aviation community, should modify the knowledge test and the PTS to fully evaluate a pilot’s risk management knowledge and skills.28

a. The knowledge test should evaluate a pilot’s understanding of risk manageme nt principles, risk identification, risk assessment, risk mitigation, and use of tools to evaluate risk on a hypothetical flight. b. The practical test should require the applicant to demonstrate application of risk management principles, risk identification, risk assessment, risk mitigation, and use of tools to evaluate risk on a scenario around which the practical test is built. The risk management objectives and tasks in the PTS should be integrated with the other objectives and tasks (i.e. preflight planni ng: complete a risk analysis).

4. Risk management training is rarely delivered effectively, or at all, during most general aviation training activity, including initial training for certificates and ratings. Most training providers probably don’t use curric ula that cover the minimum elements of risk management. There is no FAA specified curricula standard for risk management training that specifies content, presentation, completion standards, or testing provisions. **Recommendation 4:** The aviation community, especially training providers and courseware providers, should develop curricula and courseware to support risk management training. The FAA should support this effort by creating, with community support, minimum standards for risk management training. Suggested standards are in Appendix 5 to this paper.

5. The current flight review requirements do not ensure that risk management principles and procedures are included in the review. The current maneuvers - based flight review generally does not lend itself to a proper coverage of risk management subjects. **Recommendation 5:** The FAA, with aviation community support, should create a flight review ground training module that includes risk management training for the ground portion of the review while satisfying the Part 91 review requirement of Section 61.56(a)(1). In addition, the FAA and the community should create a syllabus for the flight portion of the review that incorporates risk management procedures and techniques, preferably in the form of a scenario and i n a manner that allows the instructor to cover required flight maneuvers.

6. The current Wings program does not ensure coverage of risk management training. In order to incorporate such training into Wings and encourage pilots to take such training, the prog ram needs to provide incentives that would accomplish this.29

**Recommendation 6:** The FAA, in cooperation with the aviation community, should modify the current Wings program and create a new Wings program option that would include risk management training an d offer new activity requirements that would reduce the required interval of dual flight instruction. Suggested requirements for these programs, including “notional” minimum activity threshold are contained in Appendix 4 of this paper. The following featur es should be incorporated. a. The current Wings program should include a risk management training element that would substitute for two of the three knowledge credits. One portion of the training would include risk management principles and techniques and th e second portion would include a risk management scenario. The skills credits should be similarly modified to combine two of the required three credits into a single scenario - based risk management flight. Curricula would be designed so that the material an d scenarios would cover all FAA safety emphasis areas in a risk management format. b. A new “ **PRO Wings”** option would be created for more experienced and active pilots. Two levels would be offered and each would require completion of a comprehensive risk mana gement course annually, preferably on - line. The first year course is a full course with a scenario. Each year after, the recurrent course would include abbreviated training material and a new scenario. The pilots would also be required to complete a minimu m number of flight “events” each year and remain accident, incident, and violation free. If these requirements are met, the interval between required dual instruction and maneuver skill demonstrations would be increased.30 

### Appendix 1 **– List of Cirrus Fat** **al Accidents Analyzed**

**1999 –**  **April 30, 2008 DATE**  **NTSB CASE**

**NO. RISK MGT. or** 

**SRM Accident DATE**  **NTSB CASE NO.**  **RISK MGT. or**

**SRM Accident** 3 - 23 - 99 CHI99FA112 N/A (Exp. flight test) 7 - 11 - 06 CHI06FA186 No 4- 10 -01 LAX01FA145 Yes 8 - 28 - 06 CHI06FA245 Yes 4- 24-01 NYC02FA089 Yes 9 - 15 - 06 DEN06FA131 Yes 5 - 28 -02 FTW02FA162 Yes 10 - 11 -06 DCA07MA003 Yes 11 - 3 -02 FTW03FA029 Yes 10 - 25 -06 LAX07FA021 Yes 1 - 18 -03 CHI03FA057 Yes 10 - 27 -06 ATL07FA013 Yes (1) 1 - 23 -03 LAX03FA072 Yes (1) 11 - 30 -06 NYC07FA037 Yes (1) 10 - 12 -03 ATL04WA042 Insufficient data (Spain) 12 - 18 -06 LAX07FA062 Yes 4- 19 -04 ATL04FA096 No 2 - 2 - 07 DCA07WA024 N/A (Over ocean ferry flight) 9 - 10 -04 CHI04FA255 Yes 8 - 12 - 07 ANC07WA091 Insufficient data (Canada) 12 -4-04 SEA05FA023 Yes 11 - 21 -07 NYC08FA041 Yes (1) 1 - 15 -05 IAD05FA032 Yes (1) 11 - 25 -07 CHI08FA039 Yes 1 - 20 -05 SEA05FA038 Yes 11 - 28 -07 DEN08WA037 Insufficient data (Germany) 2 - 6 -05 LAX05FA088 Yes 12 - 19 -07 NYC08WA065 Insufficient data (Brazil) 12 - 11 -05 CHI06FA043 Yes 12 - 30 -07 LAX08FA043 Yes 12 - 29 -05 ATL06FA029 Yes 2 - 2 - 08 DFW08FA060 Yes 1 - 9 -06 LAX06FA087 Yes 3 - 2 - 08 NYC08WA117 Yes 2 -4-06 MIA06FA050 No 3 - 14- 08 NYC08FA138 Yes 3 - 20 - 08 MIA08FA081 No **NOTES:** (1) Indicated accidents included other elements of poor single pilot resource management (SRM), such as automation management and task and workload management. (2) Analysis performed by author as preliminary research prior to client engagement. **SUMMARY** : Total accidents – 37 (31 analyzed, 6 with insufficient data or not applicable) **Risk management accidents**  **– 22 (71 per cent, of 31 analyzed)**  Other SRM accidents – 5 (16 per cent) Non - SRM accidents (skill based, etc.) – 4 (13 per cent)31



### Appendix 2 **– List Of Cirrus, Beech Bonanza, and Cessna 172 Accidents Analyzed**  **2007 -**  **2009 (Fatal acciden ts)**  **Cirrus Accidents DATE**  **NTSB CASE**

**NO. RISK MGT.** 

**Accident DATE**  **NTSB CASE NO.**  **RISK MGT. Accident** 8 - 12 -07 ANC07WA091 Insufficient data (Canada) 11 - 16 -08 CEN09WA065 Insufficient data (France) 11 - 25 -07 CHI08FA039 Yes 1 - 29 - 09 ERA09FA148 No 12 - 30 -07 LAX08FA043 Yes 2 - 24- 09 CEN09WA174 Insufficient data (Germany) 3 - 14-08 NYC08FA138 Yes 4- 9 - 09 DCA09WA061 Insufficient data (Morocco) 3 - 20 -08 MIA08FA081 No 6 - 19 - 09 CEN09FA363 No 4- 8 -08 SEA08FA108 Yes 7 - 18 - 09 CEN09WA454 Insufficient data (France) 4- 22 -08 DFW08FA111 Insufficient data 7 - 30 - 09 ERA09FA429 Yes 8 - 10 -08 LAX08FA265B Yes 9 - 11 - 09 ERA09FA515 Insufficient data 10 - 22 -08 CEN09WA033 Insufficient data (Switzerland) 12 - 15 -09 ERA10FAMS1 Insufficient data 11 - 13 -08 ERA09FA053 Yes **Beech Bonanza (V35) Accidents**  **DATE NTSB CASE** 

**NO. RISK MGT.** 

**Accident DATE**  **NTSB CASE NO.**  **RISK MGT. Accident** 5 - 11 -07 CHI07FA140B Yes 8 - 12 - 08 MIA08FA163 Yes 12 -9 -07 NYC08FA056 No 11 - 30 -08 ERA09FA074 Yes 12 - 20 -07 CHI08FA053 Yes 12 - 20 -08 WPR09FA061 Yes 1 - 18 -08 LAX08FA047 Yes 5 - 6 - 09 ERA09FA283 No 5 - 3 -08 NYC08FA174 Insufficient data 6 - 20 - 09 ANC09FAMS1 Insufficient data 5 - 12 -08 CHI08FA133 No 7 - 3 - 09 CEN09FA405 Yes 5 - 23 -08 LAX08FA152 No 7 - 25 - 09 CEN09FA462 Yes

(Appendix 2 analysis continues on following page)32



### Appendix 2 **– List Of Cirrus, Beech Bonanza, and Cessna 172 Accidents Analyzed**  **2007 -**  **2009 (Fatal accidents) (Continued)**  **Cessna 172 accidents DATE**  **NTSB CASE**

**NO. RISK MGT.** 

**Accident DATE**  **NTSB CASE NO.**  **RISK MGT. Accident** 1 - 2 -07 DFW07FA049 Yes 5 - 2 - 08 SEA08FA116A Yes 2 - 2 -07 ATL07FA038 Yes 6 - 22 - 08 LAX08LA191 Yes 4- 9 -07 LAX07FA123 Yes 6 - 28 - 08 DFW08WA173 Insufficient data (Spain) 6 - 3 -07 DFW07WA133 Insufficient data (Spain) 7 - 27 - 08 LAX08FA246 Yes 6 - 14-07 SEA07FA165 Yes 8 -4- 08 LAX08FA256 Yes 8 - 16 -07 NYC07FA193 No 8 - 7 - 08 LAX08FA261 Yes 9 - 2 -07 CHI07LA288 Yes 12 - 10 -08 WPR09LA056 Yes 9 - 3 -07 CHI07FA290 Yes 12 - 17 -08 ERA09FA092 Yes 9 - 8 -07 ATL07FA125 No 1 - 9 - 09 ERA09LA132 Yes 10 - 28 -07 ANC08WA016 Insufficient data (Canada) 3 - 6 - 09 WPR09LA149 Insufficient data 11 - 3 -07 CHI08FA033 Yes 6 - 1 - 09 CEN09WA333 Insufficient data (Sweden) 11 - 28 -07 DFW08FA040 Yes 6 - 28 - 09 WPR09FA316 Yes 12 - 17 -07 DEN08WA042 Insufficient data (France) 7 - 3 - 09 CEN09LA409 Yes 1 - 12 -08 MIA08FA038 No 9 - 19 - 09 ERA09LA527 Yes 1 - 20 -08 LAX08FA049A Yes 10 - 2 - 09 CEN10WA003 Insufficient data (Austria) 2 - 27 -08 ANC08FA037 Yes 10 - 25 -09 ERA10FA029 No 3 - 8 -08 DFW08FA078 Yes 12 - 7 - 09 ERA10FA091 Yes 4- 11 -08 CHI08LA101 Yes (Appendix 2 analysis concludes on next page)33



### Appendix 2 **– List Of**  **Cirrus, Beech Bonanza, and Cessna 172 Accidents Analyzed 2007** **- 2009 (Fatal accidents)**  **(Continued) Summary of Risk Management Classification of GA Fatal Accidents** 

**For Three Selected Aircraft 2007** **- 2009**  **Aircraft Model Pilot**  **Risk**

**Management Accidents**  **Pilot Skill** 

**Accidents ( not**  **related to risk management)**  **Aircraft Related**

**Accidents ( not**  **related to risk management)**  **TOTAL** Cirrus SR22 7 (**70%)** 2 1 10 Beech 35 8 **(67%)** 3 1 12 Cessna 172 24 **(86%)** 4 0 28 **TOTAL** 39 **(78%)** 9 2 50

NOTES: 1. Research performed by author to support article for Aviation Safety magazine.34 

### Appendix 3 **– List of Arizona Fatal Accidents Analyzed** 

**2001 -**  **2010 DATE**  **NTSB CASE**

**NO. RISK MANAGEMENT** 

**Accident DATE**  **NTSB CASE NO.**  **RISK MANAGEMENT**

**Accident** 4- 10 -01 LAX01FA145 Yes 3 - 19 - 06 LAX06FA130 Yes 4- 30 -01 LAX01FA160 No 6 - 18 - 06 LAX06FA206 Yes 9 - 16 -01 LAX01LA286 Insufficient data 7 - 23 - 06 LAX06FA243 Yes 12 - 5 -01 LAX02FA041 Yes 9 - 2 - 06 LAX06FA283 No 6 - 8 -02 LAX02FA191 Yes 9 - 24- 06 LAX06FA304 Yes 6 - 29 -02 LAX02FA210 Yes 10 - 18 -06 LAX07FA012 Yes 9 - 8 -02 LAX02FA278 Yes 10 - 25 -06 LAX07FA021 Yes 9 - 14-02 LAX02FA285 Yes 11 - 17 -06 LAX07LA037 No 10 - 12 -02 LAX03FA005 No 12 - 18 -06 LAX07FA062 Yes 11 - 18 -02 DEN03FA012 Yes 4- 9 - 07 LAX07FA123 Yes 1 - 1 -03 LAX03FA057 No 4- 15 - 07 LAX07LA130 Yes 1 - 8 -03 LAX03FA069 Yes 5 - 11 - 07 LAX07FA160 Yes 1 - 11 -03 LAX03FA066A Yes 7 - 15 - 07 SEA07FA199 Yes 1 - 26 -03 LAX03FA076 Yes 8 - 14- 08 LAX08FA267 Yes 4- 21 -03 LAX03LA139 Yes 8 - 16 - 08 SEA08LA179 Yes 9 - 21 -03 DEN03FAMS1 Insufficient data 8 - 20 - 08 SEA08FA187 Yes 11 - 13 -03 LAX04FA042 No 11 - 13 -08 WPR09FA038 No 12 - 28 -03 ANC04FA016A Yes 6 - 24- 09 WPR09FA309 Insufficient data 5 - 31 -04 LAX04FA223 Yes 8 -4- 09 WPR09LA384 No 8 - 28 -04 LAX04FA304A N/A – Airshow midair 8 - 17 - 09 WPR09FA400 Insufficient data 8 - 28 -04 LAX04FA304B N/A – Airshow midair 10 -4- 09 WPR10FA005 Yes 11 - 16 -04 LAX05FA029 Yes 3 - 11 - 10 WPR10LA156 N/A – Experimental 1 - 8 -05 LAX05FA062 Yes 6 - 11 - 10 WPR10FA287 Yes 1 - 18 -05 LAX05LA073 Yes 6 - 18 - 10 WPR10FA305 Yes 9 - 2 -05 LAX05LA286 No 8 -4- 10 WPR10FA383 No 10 - 22 -05 LAX06LA016 Yes 9 - 27 - 10 WPR10FA473 No 12 - 31 -05 DEN06FA028 Yes NOTE: Analysis performed by author in support of presentation to Arizona Pilots Association.

**DATA SUMMARY –**  **ARIZONA FATAL ACCIDENTS, 2001 -**  **2010 (53 Files; 46 with sufficient relevant data)**  **Pilot Risk**  **Management Accidents**  **Pilot Skill Accidents (** **not related to risk**  **management) Aircraft Related**  **Accidents**

**( not**  **related to risk management)**  **TOTAL** 35 (76%) 4 (9%) 7 (15%) 46 (100%)35



### Appendix 4 **– Proposed Enhanced FAA Pilot Proficiency Program**  **(PRO Wings) ELEMENT**  **Current**

**flight review**  **(See note 1)**  **Current**

**Wings program**  **(See note 1)**  **PROPOSED NEW OPTIONS INCORPORATING**

**RISK MANAGEMENT TRAINING Modified**  **flight review**  **(See note 1) Modified** 

**Wings program**  **(See note 1) New** 

**PRO Wings** **** **Level A New** 

**PRO Wings** **** **Level B Minimum total flight**  **time to participate** 40 40 40 40 200 500 **Minimum Time in aircraft type**  0 0 0 0 50 100 **Minimum annual flight hours (Note 1)**  4 5 4 5 50 100 **Minimum quarterly flight hours (Note 1)**  1 1 1 1 5 8 **Minimum quarterly takeoffs and landings**  **(Note 1)** 3 3 3 3 10 15 **Minimum annual flights in “system” for IFR priv.**  **(Note 1)** 0 0 0 0 6 10 **Minimum IFR currency flights (Note 1)**  **(QTR/ANN)** 0/2 0/2 0/2 0/2 1/6 2/10 **Risk Mgt. Training required?**  No Optional Yes Yes Yes Yes **Must maintain**  **ACC/IND. + violation free?**  No No No No Yes Yes **Maximum interval between required dual**  **instruction (years)** 2 1 2 1 3 4 **Nature of required dual instruction: maneuver**  **– based (MAN) or**  **scenario -**  **based (SCEN)** MAN MAN MAN MANEUVER + SCENARIO MAN +

SCEN MAN +

SCEN NOTE 1: All of the times and events noted for the flight review and current Wings program are the estimated minimums needed to maintain passenger carrying privileges.36 

### Appendix 5 **– Proposed Minimum Standards for**  **Initial and Recurrent Risk Management Training** A. Initial flight review, proficiency check, Wings, or PRO Wings training 1. Knowledge requirements (Annual on - line or classroom training) (Est. 3.0 hours)  Risk management principles (accept no unnecessary risk, etc.)  Risk management three phase process (identify, assess, mitigate)  Risk identification procedures ( **PAVE** checklist, etc.)  Risk Assessment procedures (using risk assessment matrix, etc.)  Risk mitigation procedures (**TEAM** checklist, etc.)  Accident case review(s) illustrating risk management issues  Use of flight risk assessment tool (FRAT) using a case study  Testing element to ensure comprehension 2. Skill requirements (During in -flight or approved simulator events)  Use FRAT to assess planned flight  In -flight risk management scenario created by instructor  Post -flight student - centered debriefing  Provisions for both airplane and appropriate simulation  Maneuver skill demonstration emphasizing fatal accident causes B. Later flight reviews, proficiency checks, or Wings training 1. Knowledge requirements (required annually) (Est. 2.0 hours)  Abbreviated coverage of initial training items  Accident review  Case study 2. Skill requirements  Same as initial event C. Approval, delivery and completion standards 1. Approval/acceptance b y FAA or delegated entity 2. On - line delivery preferred (with provisions for live training) 3. Required testing (progressive or final) with directed correction of wrong answers 4. Testing includes case study example with realistic scenario37 

### Appendix 6 **– Reference**  **s** Risk Management Handbook (FAA- H - 8083 - 2), Federal Aviation Administration, 2009 WINGS – Pilot Proficiency Program, Advisory Circular AC 61 - 91J, Federal Aviation Administration February 2011 Fatal accident case documents, National Transportation Safety Board Introduction of Glass Cockpit Avionics into Light Aircraft, Special Study SS - 10/01, National Transportation Safety Board, 2010 Changes in General Aviation Flight Operations and Their Impact on System Safety and Flight Training, Robert A. Wright, published by American Institute of Aeronautics and Astronautics, AIAA 2003 - 2639, July 2003 General Aviation Technically Advanced Aircraft, Final Report of TAA Safety Study Team, FAA/Industry Safety Study, August 2003 “Analyzing Fatals”, Robert A. Wright, Aviation Safety magazine, March 2012 Additional references and studies on the FAA Industry Training Standards (FITS) program, available at www.faa.gov/training_testing/training/fits