Safety

Safety Watch: Managing Risk

By Tim McAdams | September 1, 2003

How much does personality contribute to accidents?

One pilot’s final radio transmission was, “Watch this.”

Risk. It permeates every aspect of life. Yet, all too often we give little thought to effective risk management. For aviation, it is vital. Risk management’s primary application should be in preventing an accident. However, since a zero accident rate is unrealistic, it is equally important to use risk management to minimize the damage from an accident. Many accidents happen because pilots and managers fail to accurately assess and control risk.

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Past accidents offer a window into how operational mistakes and other problems can contribute to accidents and, more importantly, what can be done to prevent those contributions. Decades of investigations have made clear that most accidents happen because of a series of events rather than a single one. The series can be complex, given the diverse ways the mind processes and perceives data.

Factors like complacency, judgment, attitude, experience and training can have a profound effect on safety. Human dynamics are a major cause of accidents. Therefore, they should be part of risk assessment. This will raise many good questions. For instance, is possession of an instrument rating without maintaining currency enough to prevent or reduce accidents involving continued flight into instrument meteorological conditions (IMC)? Will use of night vision goggles help reduce accidents? Is experience a good measure of the potential for a pilot to have an accident? Future columns will discuss such questions and how they relate to specific accidents.

Poor judgment can easily creep into an experienced pilot’s decision-making process. On April 3, 1999, a VFR-equipped BO105 crashed at night near Indian Springs, Nevada. The ATP-rated pilot and two crewmembers died. The pilot had 10,920 hr. total, 6,580 in helicopters and 3,592 on instruments. A motorist saw a helicopter overhead at 150-200 ft. using a searchlight to follow the highway. Another who saw it over the highway said the sky was overcast, with freezing rain that turned into wet snow and visibility at 50 ft. The NTSB determined the pilot’s decision to continue VFR flight in deteriorating IFR conditions led to spatial disorientation and loss of control.

Why would a pilot with enough experience to fully understand the consequences of pushing weather do so? In this case, pathological information might indicate why. Toxicological tests on the pilot were positive for an over-the-counter, sedating antihistamine, an over-the-counter decongestant and a local anesthetic. It’s possible these drugs affected the pilot’s thought process. State of mind, physical health, and experience all play roles in the risk equation.

Would better training or instrument currency have helped? Maybe, but icing would have been a concern. The best answer would have been to stay on the ground.

Proper training is also an important component of effective risk management. Consider the January 10, 2003 crash of an Agusta A109-K2 in Salt Lake City during night IMC. The instrument-rated commercial pilot and a flight paramedic died. A flight nurse was seriously injured. The pilot had aborted a mission for deteriorating weather and was holding west of Salt Lake City International Airport when he entered IMC and declared an emergency. There were no subsequent radio communications. Wreckage was found a half-mile southwest of the approach end of Runway 34L. Weather was 1/8-mile visibility in fog, with vertical visibility of 200 ft. Suddenly transitioning from visual references to instruments near the ground and without an approved obstacle avoidance procedure is psychologically demanding for a pilot that routinely flies IFR. For a pilot with little experience or minimal training, it can be overwhelming.

How much contribution can personality make to an accident? A Miami Sky 6 pilot’s final radio transmission was “Watch this,” as he attempted a hammerhead turn in an MD600N, which broke up in flight. He and his cameraman were killed. The pilot was well known for hot-dogging. He’d lost his airman certificates for a drug conviction involving an aircraft. Drug use in the accident was undetermined, but the pilot’s brain and liver showed previous cocaine use. His reckless lifestyle was a telltale sign of an impending accident. No one is immune to mistakes. But willfully choosing a dangerous action with no possible productive outcome is poor risk management.

It is my intent with this column to provoke thought and debate on safety issues and raise awareness of risk by addressing these kinds of questions. I don’t intend to criticize other pilots. That would be unproductive and unfair. Many experienced pilots who have said, “I would never do that,” might be surprised at what happens under the stress of an emergency.

You can send questions or comments to Tim McAdams at rotornwing@pbimedia.com.

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