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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 an 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

Bellingham, 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

757-496-2858 (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 service 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, experimental 

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.”
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Relief/enhancement requested and reason for request: The 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 high activity, the petitioners believe that they would not require 

annual dual instruction under the WINGS program. These pilots would, however, be required to 

successfully perform the following requirements:

1. Complete an annual risk management course accepted by the FAA.

2. Remain 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-based 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 extended to at least two years, the current minimum requirement 

for the flight review specified 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, unlike the current flight review, this should be a 

structured flight with specified standards for successful completion. The petitioners believe that 

the flight 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 instructional 

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 Risk 
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Management as a Major Determinant of General Aviation Fatal Accident Root Causality: Some 

Pilot Training Implications is contained in this petition following the main body of the text 

under the section “Supporting 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 management 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 such as automation management, task and workload 

management, and situational 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 from 

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 participants 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 instrument 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 – The petitioners recognize the importance of basic 

flight skills and the fact that these skills may deteriorate over time. We believe that this 
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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 through 

the cooperation of training organizations as represented 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 flat 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 the 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 co-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 management. Furthermore, there is no requirement for risk management 

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 WINGS 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 from 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; risk identification, assessment, and mitigation procedures; 

accident examples and illustrations; a relevant case study; and, a final examination. Petitioner 

Robert Wright completed the three courses 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 WINGS program flight credit elements do not 

adequately emphasize risk management. The three credit requirements are maneuvers-based 

and emphasize elementary flight and training maneuvers. This may be appropriate for pilots 

with low total flight time or for pilots who fly infrequently, but may not address more important 
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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 

risk 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 

accidents. 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 aircraft time every 

two years. The WINGS program requires from 3-6 hours of ground instruction and/or class time 

(although this is often at no cost), three hours of flight instructor time, and three hours of 

airplane time. If the interval for training was extended for more experienced pilots, then 

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 adequately 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 petitioners 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, participants would have to meet 

continuing activity levels and complete an annual risk management knowledge refresher 

course. At the two year point, they must again complete a scenario-based skill flight with an 

instructor.
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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 organizations, such 

as the co-petitioner representing Beech aircraft models. The FAA may even wish 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 Appendix 4 of the 

attachment. The petitioners suggest that FAA and the aviation community collaborate to 

analyze accident and other data to establish program parameters and create detailed content 

and participation 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 training 

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 associated 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 financially 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 

mission 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. 
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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 

instructor 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 other hand, 

would require perhaps nine hours 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 PRO WINGS 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 rather 

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 accidents 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 improved 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 SRM and risk 

management training. 

The petitioners also note that the FAA has formed 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 appropriate 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 Certification 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 intent 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.
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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 

because 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 interval for required dual 

instruction could be extended 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 reduce 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 Wright in May 2013, and revised in July 2013.

(Analysis begins on next page)
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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.
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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 Fatal 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 – References 
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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, and/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 risk 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 is 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 been 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.
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II. Disclosures

The author of this paper, Robert A. Wright, is a well-known aviation 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 as 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 Aviation 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 Albuquerque, 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 currently 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 develop 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 general aviation pilot 

training. In this manner, he hopes to influence development of FAA and industry programs to 

reduce the number of these accidents.
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III. Background

The general aviation fatal accident rate stagnated during the period 2001-2010. It remained 

essentially 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 accidents, 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, consider 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 determine “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.
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Another element of the FITS program examined the impact of new flight technologies 

available in emerging technically advanced 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 general 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 limited 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 significant role in these other populations as well as in non-fatal general 

aviation accidents.
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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 accidents 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 population 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 experience.

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 multipart test to determine if the 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) checklist 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 likelihood 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 risk management accident. 
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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 readily 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 flight. 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 

whether 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 

own 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 conservative 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 and 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 presentation 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 Cirrus 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 higher 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 involving 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 and 

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 fixed 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 management 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 11 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 skill 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 category. 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 hazards 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 accidents 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 

populations 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 noted 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 of 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 an 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 have 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 address 

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 practical 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 other 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 2009 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 needed 

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. The 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 documents. 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 are 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 analyze general aviation accidents and 

this has resulted in pending recommendations for incorporating risk management and other 
22

higher order pilot skills in general aviation training. As the author was completing this paper, 

the GAJSC Loss of Control Work Group 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-Pilot 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 curricula 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 simulation 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 concepts. 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 

scenario-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-type 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 handbooks 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 order 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 in 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 through 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)

 Complete 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 instructor 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 practical 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 knowledge 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 airport 

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 acknowledges 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 risk 
24

management requirement, content control, and effective testing of comprehension, 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 than 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 concludes that neither the flight review nor the Wings 

program effectively cover risk management 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 would 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 regulations 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, every 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 course, 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.

With 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 is 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 associated 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 could 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”, the 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. The 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 

expanded 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, should 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.

Recommendation 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 management 

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 planning: 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 curricula 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 in 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 program 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 and 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 features 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 the 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 and 

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 management 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 minimum 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 Fatal 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 accidents)

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 

WingsLevel A

New

PRO 

WingsLevel 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 by 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 scenario
37

Appendix 6 – References

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