T T CF Flight risk Assessment
To ol
by Bob Thomason, Editor
History
Last month we announced the formation
of a team to develop a Twin Cessna
Flight Risk Assessment Tool (FRAT). We
have completed the process and you can
find a copy of the completed tool on our
website at www.twincessna.org
Historically, The Twin Cessna Flyer has
never had an official Safety or Pilot
Proficiency program as some other type
clubs do. One reason is we feel that all
twin pilots should attend some sort of
simulator-based training annually. That
plus the systems knowledge gained
from our own Systems and Engine
courses can give a Twin Cessna pilot a
tremendous leg up on proficiency. For
those pilots who want training in their
own airplane, we have an excellent
cadre of instructors available to us who
specialize in our aircraft. Their names
and contact information are listed in the
Classified section of each magazine and
on the website.
We recently decided to augment this
approach to safety by developing a
TTCF Flight Risk Assessment Tool as
our first step. First some background on
FRAT’s.
What Is a FRAT and How Is It Used?
A lot has been learned about risk
and safety in the last 30 years. This
is particularly true of aviation. Think
about the incredible safety record of
the large schedule air carriers. The
same is true of other industries that
utilize complex equipment. Historically,
accidents happened, causes were
determined and procedures were
developed to prevent the same accident
from happening again. Over time,
safety-conscious industries began to
become proactive in their approach
to risk, identifying areas of risk in
advance and developing procedures
to mitigate those risks. Using this
approach, safety began to improve
dramatically. This business-like,
proactive approach to risk management
resulted in the development of formal
Safety Management Systems (SMS).
Documented SMS’s are now required
by the ICAO for large commercial air
carries operating overseas. The FAA
20 | TWINCESSNA.ORG
is engaged in a rule-making process
that may extend the requirement to
commercial carriers the U.S. To learn
more about SMS’s and aviation see:
http://www.faa.gov/about/initiatives/
sms/
The Flight Risk Assessment Tool is one
small part of an aviation SMS, but a
part that is immediately applicable to
our operations as Twin Cessna pilots.
Simply put, a FRAT is a risk checklist
that incorporates a method for: 1)
identifying individual risk factors
that apply to a particular flight and
2) estimating the total risk involved
in making the flight. To use a FRAT, a
pilot simply notes all the risk factors
present, lists the corresponding Risk
Value (a 1 to 5 scale) in the rightmost
column and adds up the total Risk Value
Score. If the score is greater than 25, we
(continued on page 22)
TTCF FRAT
(continued from page 20)
recommend the flight be scrubbed or
that individual risk factors be mitigated
to reduce the score to an acceptable
level. That said, we recognize that all
pilots approach risk differently and
different pilot capabilities influence
how much risk a certain factor entails.
Therefore, consider this tool a starting
point for your own personal FRAT.
Modify it to fit your experience level,
your equipment and flight profiles.
And one more caveat, nothing in the tool
is meant to supersede FAA regulations
or your Aircraft Flight Manual
instructions or recommendations. It is
assumed that for every flight, you, your
airplane and your planned flight are in
full compliance with the FAR’s.
TTCF Tool Development
We assembled a team of five TTCF
members and advisors to develop our
Twin Cessna FRAT. The team names
and bios are listed on page 6 of the
April issue. Our combined experience
includes:
• over 30,000 hours total flight time
• over 10,000 hours of Twin Cessna
flight time
• 2 active CFII’s and Twin Cessna flight
training specialists
• 1 Twin Cessna maintenance specialist
with 30 years experience
For our starting point, we all did our
own individual research, reviewing
accident reports and drawing on
personal experience. We then began
with the generic FAA FRAT. This tool
required considerable customization
since it was developed for professional
2-pilot crews flying turbine equipment.
We went through this tool line-by-line
and adapted it for our airplanes and
the type of flying most of us do, by
choosing the individual Risk Factors
and assigning Risk Values. In spite of
each of our individual experience levels,
it was an incredible learning process to
hear everyone on our team share their
perspectives on risk. The process of
thinking through the tool helped each
of us fine-tune our thoughts on flight
risk. In this article, and several that
22 | TWINCESSNA.ORG
will follow, we will share our thought
process on each line item of the tool.
This article will address the No-Go/
Personal Minimums page and the Pilot
Qualifications section. Future articles
will address the Operating Environment
and Equipment sections.
No-Go/Personal Minimums Page
First things first. If you, your airplane
or your planned flight are not in
compliance with the FAR’s, there is
no need to complete the FRAT. Your
flight is scrubbed until you correct the
deficiencies. The same applies to your
personal minimums. If they are not met,
you don’t fly. Assuming these minimums
are met and all regs are complied with
it’s on to the FRAT risk factors.
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Pilot Qualifications and Experience
Section
The first thing you’ll note about this
section is the high individual risk values.
All are 5’s, the maximum value, except
for one 4. They are higher, on average,
than those of the other sections. Why?
Two words: “Pilot Error” - the cause
of the vast majority of general aviation
accidents. Our review of Twin Cessna
accident reports revealed a high number
where the pilot had either low time-intype or a lack of recent experience and,
in many cases, both.
#1: Less than 200 hours in Type. Risk
Value =5. Again, one cannot read the
accident reports and not conclude that
low time-in-type is a huge risk factor.
The insurance carriers have stringent
requirements for pilots transitioning to
Twin Cessnas but regardless, it takes
considerably more experience to become
truly comfortable and proficient. One
accident report we reviewed included
a 414 pilot who perished on the very
first flight after flying off his 50-hour
insurance company mandated dual
instruction. Our group felt it takes
roughly 200-hours in type before the
risk level stabilizes. In this case, we
agreed with the FAA value.
#2: Less than 30 hours in the last 90
days. Risk Value = 5. How much we’ve
flown recently affects our proficiency.
We’ve all felt “rusty” after a period of
not flying. Professional pilots often say
the rust is apparent after as little as one
week out of the cockpit. This line item is
an attempt to measure the “rust factor”.
The FAA tool says 100 hours in the last
90 days is appropriate (400 hours a
year). Few Twin Cessna Pilots fly that
much. Most of us fly in the 100 to 120
hour per year range. We know we’d be
more proficient at 400 hours a year but
we accept the risk of reduced flying. Our
team felt with less than 30 hours time in
the last 90 days, we begin to incur some
additional risk.
#3: No type-specific recurrent training
in the last 12 months. Risk Value =
5. A BFR is really not enough. Every
Twin Cessna pilot should have annual
recurrent training either in a simulator
or in your airplane or both (best). You
simply must practice handling engine
out situations if you are to have any
realistic hope of successfully handling
one in real life. Additionally, most every
pilot can benefit from an IPC annually.
Those of us who fly a lot may have no
problem staying legally current on
instruments - but it’s mostly by shooting
a lot of ILS and GPS approaches at
familiar airports with an occasional
hold or missed approach. Only recurrent
training gives us practice shooting
unfamiliar NDB, VOR or circling
approaches with their step downs and
dog-legs that often trip us up.
#4: “Duty day” exceeds 14 hours.
Risk Value = 4. Flying at the end of
a long day entails greater risk. How
much depends on what you did during
the day. Attend business meetings? A
football game? Nap at your in-laws’
house? Ultimately, you are the judge but,
regardless, if you are flying 14 hours
after you woke then you are probably
not as sharp as you were earlier in
the day. The FAA tool specifies a 12hour duty day, so we liberalized this
a little, recognizing that most of us
are not professional pilots and are not
necessarily “working” between flights.
Our tool doesn’t address this directly
but if you are flying at a time when you
normally would be sleeping (early AM
or late PM for most of us), the risk goes
up as well. Studies show our body tends
to preserve it’s internal rhythm and goes
into a lower state of alertness at these
times.
#5: Feeling tired, ill or under stress.
Risk Factor = 5. In many cases, this
might be a “no-go” item. If you are not
functioning at your normal level, for
whatever reason, it’s probably a good
idea to scrub the flight. But ultimately
you are the judge. A short, routine VFR
flight before you’ve completely recovered
from that cold you had might be OK. A
long, IFR flight to an unfamiliar airport
with a likely instrument approach at the
end would not be advisable. We are on
the honor system but the stakes are high.
An observation: the accident reports are
full of pilots who perished while having
various levels of disqualifying drugs
in their system - both prescription
and nonprescription. It’s important
to know what is allowed and what
isn’t. You may not think the drug
affects your ability to fly, but the
accident reports may say otherwise.
Be conservative here. The pilot is
the one part of the system that has
to be squawk-free.
you drive? Take the airlines? Wait a day?
Think all this through in advance and
do what you can to make the alternative
palatable. I’m a huge believer in
“visualization.” So when I’m thinking
through my alternate plans, I visualize
myself renting the car and getting my
hotel room for the evening. It makes the
actual decision much easier to make if
I’ve already “made” it.
Another tip that’s worked for me
over the years is managing passenger
expectations. If the weather looks
questionable a few days before the trip,
I’ll give the passengers a “heads up.”
In my charter flying, I would also give
them a probability estimate: e.g. “there’s
a 20% probability we won’t be able
to make the trip on Wednesday.” If I
thought there was a 50%
chance or greater that we
couldn’t fly, I’d suggest
they develop a backup
plan for their trip. At that
point, the pressure was off
me and on them. Not once
in my flying career have I
had a passenger express
dissatisfaction with
conservative decisionmaking even though most
of the trips I’ve cancelled
could have been flown safely.
Here’s a sad story to illustrate this
risk factor. A 414 took off from an
uncontrolled field at night in low
weather. It crashed about a mile off the
end of the runway, killing the pilot and
his 2 passengers. In the prior 24 hours
he obtained 17 weather briefings. What
would make a pilot attempt this flight
when he was clearly so concerned about
the weather? A “solid gold alternate
plan” might have saved his life.
Next month, I’ll discuss the Operating
Environment section of the FRAT. In the
meantime, download the tool from our
website, customize it as need and begin
using it.
#6: External pressure to complete
the trip. Risk Factor = 5. “Getthere-itis” has killed many a pilot
and his passengers. If you are under
pressure to make the flight, you are
at great risk, period. It will affect
your decision-making should any
challenging issues arise. The good
news is that this risk generally can
be mitigated by thinking ahead and
creating what one of my instructors
once termed “solid gold alternate
plans.” What if you get in your
airplane and one of the engines
won’t start? What if you can’t fly
home the day you planned? Will
THE TWIN CESSNA FLYER • MAY 2011 | 23
T T CF Flight risk Assessment
To ol - part 2 - part 2 by Bob Thomason, Editor
What if you had an instrument on your
panel that very accurately showed you
the risk involved in making a particular
flight? What if you started your airplane,
flipped on the avionics master and saw
the picture to the right?
Would you go flying knowing that what
the instrument was telling you was that
a lot of pilots have died trying to make
a similar flight? Hopefully, you’d try to
determine what was making the flight
so risky and then mitigate some of the
risk factors. This is the idea behind the
Flight Risk Assessment Tool.
Last month we introduced the Twin
Cessna Flyer Flight Risk Assessment
Tool (FRAT). We discussed this history
of its development and explained
how these tools are being adopted
by professional flight departments
worldwide. We discussed the Pilot
Qualifications and Experience section in
detail. In this issue, we’ll review the next
section: Operating Environment.
The Operating Environment section
contains the greatest number of risk
factors of any of the three sections.
This makes sense as there are so
many variables associated with the
environment in which we fly. However,
some of these variables raise the risk
level of a flight more than others so
the risk values assigned to them vary
more than do the Pilot Qualifications
and Experience risk values. Generally,
anything that impacts the ability of
the pilot to fly the airplane has a big
impact on risk, whereas a challenge
in the operating environment may
have a smaller risk factor particularly
depending on the capabilities of the
pilot or aircraft. Let’s dive into this
section. But rather than discuss each
risk factor, I just want to highlight
a few that require explanation. And
remember: nothing in the tool is meant
to supersede FAA regulations or your
Aircraft Flight Manual instructions or
recommendations. It is assumed that for
every flight, you, your airplane and your
planned flight are in full compliance
with the FAR’s.
#7: No published approach. Risk Value
= 3. We debated this factor quite a bit.
Some of us felt it was too situational.
20 | TWINCESSNA.ORG
That is, on a clear VFR
day with no IMC within
a couple hundred miles
there’s not much risk
in launching towards
an airport without an
instrument approach.
On the other hand, the
accident statistics show
a significant number of
(continued on page 22)
Would you make the flight if your panel mounted “Risk
Meter” looked like this?
TTCF FRAT - Part 2
(continued from page 20)
accidents involving pilots trying to land
in IMC at airports with no approaches.
One example: An air ambulance pilot
flying a 340 was attempting to return a
nurse to the uncontrolled, no-approach
airport where the nurse’s car was
located. He crashed in ground fog,
killing both of them. The NTSB report
noted that on the glareshield were
charts for two nearby airports that had
instrument approaches. This type of
accident should never happen but it does
with some regularity, so we included it
as a risk factor.
#9: Circling Approach - Day (Night)
Risk Value = 3 or (5). It is generally
accepted that circling approaches are
the riskiest instrument approaches. And
circling approaches at night compound
the risk. Remember, if you are at circling
minimums, at most airports that will be
well below pattern altitude. The visual
picture is much different from what
we’re normally used to and things can
go wrong in a hurry. When was the last
time you practiced a circling approach?
Our team debated on just how much
additional risk is incurred. Many flight
departments prohibit night circling
approaches. We gave them the maximum
risk value but several on our team felt
a flight that would knowingly end in
a circling approach at night would
be a “no-go”. I was one of them even
though I practiced them regularly and
performed them twice a year on FAA
checkrides.
#10: No weather reporting at
Destination. Risk Value = 5. We also
debated this risk factor. Some of us
felt the actual risk varies considerably
depending on particular circumstances.
What if the nearest reporting station is
only 5 miles away? What if it’s 50 miles
away? What if you will have 2 hours
fuel remaining when you arrive? Or
just 45 minutes? But the bottom line is
if there is if no weather reporting, you
can’t really know what the weather
is. We had the same debate about #11:
Alternate Not Selected. The risk is
highly dependent on the circumstances.
When our team disagreed, we opted to
go with the most conservative opinion
which we did in both of these cases.
22 | TWINCESSNA.ORG
“5” is also the same risk value the FAA
chose on its template tool, indicating
some statistical validation.
#13 through #17: Ice, Thunderstorms,
Severe Turbulence, Winter and Night
Ops: the risk associated with these
factors is obvious and confirmed by
accident statistics. No further comments
from our team.
#18: High Terrain Surrounding Airport.
Risk Factor = 3. The FAA uses the phrase
“Mountainous Airport”. We’ve read
so many accident reports of airplanes
colliding with hills (high terrain) around
airports in non-mountainous terrain
that we felt it was important to make
this distinction. Most pilots are on high
alert when flying in mountainous areas.
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They seem to sometimes be lulled into
complacency when in flatter country.
The classic accident is a pilot departing
into marginal VFR and then having
difficulty picking up an IFR clearance.
He flies around waiting for ATC to
respond and hits something. The lesson
is, of course, to always know where
you are relative to the surrounding
terrain (and to get your clearance on the
ground, if possible, when in marginal
conditions.)
#19: Runway length < accelerate/stop
distance (if unavailable, use takeoff
distance plus 1/2 landing distance). Risk
Factor = 2. and
#20: High density altitude and
maximum gross weight takeoff. Risk
Factor = 5. Short runways limit options,
particularly if anything goes wrong. It
is important to do a weight and balance
and takeoff performance calculation
whenever runway length might be a
concern. The very best option for dealing
with an engine failure on takeoff is to
cut the power and land straight ahead if there is runway available. The shorter
the runway, the less time the pilot has
to exercise this option. While we don’t
yet know exactly what caused the 310
accident in Palo Alto, CA (KPAO) in
February of 2010, we do know that the
pilot and his 2 passengers departed a
2,450 foot runway in IMC conditions
and veered left instead of right as called
for in the Departure Procedure, hitting
power lines and crashing close to the
airport. If an engine problem was a
factor, the short runway eliminated
any chance of cutting the power and
aborting the takeoff. And don’t assume
that just because you’ve used a short
runway before, you’ll get the same
performance when you use it again. A
320 pilot in FL routinely used a 3,000
ft. turf strip with the same passenger
load. On one particularly hot day, he
mushed into the trees after takeoff,
killing one of his passengers. A review
of the performance data from his POH
would have warned him of the degraded
performance that day. Using short
runways definitely increases flight risk.
#22: Planned flight into last hour of
fuel. Risk Factor = 3. Fuel exhaustion
is a continuing cause of Twin Cessna
(and all GA aircraft) accidents.
Detailed fuel and range calculations,
conservative alternate selection and
enroute monitoring of changing weather
conditions are critical. With a nod to
the wisdom of aviation writer Richard
Collins, we favor this one simple
guideline: if you are flying in your last
hour of fuel, the risk increases. Plan
carefully for it.
No FRAT can be a true one-size-fits
all document. Each pilot will need to
customize it to his/her particular skills
and aircraft. But experience shows that
using a FRAT can decrease the risk
associate with your flying. The pros do it
and we should too.
Download the tool from our website,
customize it as need and begin using it.
Next month, we’ll discuss the equipment
section.