1. AERONAUTICAL DECISION MAKING + SINGLE PILOT RESOURCE MANAGEMENT = OPERATIONAL RISK MANAGEMENT

2. CGAP Decision Making/Risk Management Definitions Aeronautical Decision Making (ADM): systematic approach to consistently determine the best course of action to a given set of circumstances Automation Management (AM): demonstrated ability to control and navigate an aircraft by means of the automated systems installed in the aircraft Operational Risk Management (ORM): decision-making tool to systematically help identify operational risks and benefits and determine the best courses of action for any given situation. Single Pilot Resource Management (SRM): art and science of managing all the resources (onboard aircraft and outside sources) available to a single pilot (prior to and during flight) to ensure the successful outcome of the flight is never in doubt. Situational Awareness (SA): the accurate perception and understanding of all factors and conditions within the four fundamental risk elements (pilot, aircraft, environmental, external pressures) that affect safety before, during and after the flight. Task Management (TM): process by which pilots manage the many concurrent tasks that must be performed to safely and efficiently fly a modern aircraft.

3. CGAP Decision Making/Risk Management Acronyms AOE: Areas of Evaluation CFIT: Controlled Flight Into Terrain D-E-C-I-D-E: Detect-Estimate-Choose-Identify-Do-Evaluate I-A-D-E: Identify-Analyze-Decide-Execute I-A-A-D-E: Identify-Analyze-Assess-Decide-Execute IFR: Instrument Flight Rules IMC: Instrument Meteorological Conditions I-M-S-A-F-E: Illness-Medication-Stress-Alcohol & drugs-Fatigue-Eating MEA: Minimum Enroute Altitude P-A-V-E: Pilot In Command-Aircraft-enVironment-External Pressures T-E-A-M: Transfer-Eliminate-Accept-Mitigate

4. CGAP Decision Making/Risk Management "Tools" The following Risk Management/Decision Making "Tools" are FAA AOE's for future pilot certification tests: - SRM - ADM - ORM - TM - CFIT Awareness CGAP has incorporated some of these "tools" in its Decision Making/Risk Management Model - ADM/SRM/ORM Using versions of or the actual "tools" below: D-E-C-I-D-E; PPP's, 5P's, PAVE, I-M-S-A-F-E, T-E-A-M How does it all fit together?

5. CGAP Decision Making/Risk Management TREE

6. CGAP Aeronautical Decision Making: "I-A-D-E Loop"

7. CGAP Decision Making/Risk Management TREE

8. CGAP Decision Making/Risk Management: SRM & "5P's"

9. SRM and the "5P's" "5P's"- a scheduled review at key points in the flight where decisions are most likely to be effective: - pre-flight - before takeoff - midpoint cruise - before descent - before initial approach segment or pattern entry - anytime an emergency or abnormal situation occurs PLAN- mission or task: weather, route, fuel, publications, ATC, nature of flight PLANE- status/condition: mechanical, database currency, automation, backup systems PILOT: I-M-S-A-F-E Illness: symptoms, do I feel well? Medication: am I taking medication which is not approved for flying? Stress: am I under emotional stress or psychological pressure? Are there personal distractions? Alcohol & drugs: have I consumed alcohol within the last 8, 12, 0r 24 hours; do I use controlled substances? Fatigue: have I had sufficient rest; am I sleepy? Eating: am I adequately nourished; do I have too low a blood sugar level or too high a caffein level?

10. SRM and the "5P's" "5P's"- continued PASSENGERS- pilot, non-pilot, experienced vs nervous flyer, quiet vs disruptive PROGRAMMING- avionic, navigation management systems, flight control systems, EFIS, powerplant management systems

11. CGAP Decision Making/Risk Management TREE

12. Operational Risk Management Elements

13. HAZARD Definition Condition, or circumstance which can lead or contribute to an unplanned or undesired event such as a mishap. Examples: thunderstorms; wet or icy runways; obstacles in approach or departure path; FOD

14. Operational Risk Management Elements

15. Analyze Hazard: P-A-V-E PILOT: certificate level, competency in aircraft, currency, experience AIRCRAFT: performance, equipment, airworthiness, condition ENVIRONMENT: weather, airport condition EXTERNAL PRESSURE: purpose of flight, job, family, commitments

16. Operational Risk Management Elements

17. Risk Vs Benefits Analysis LEVEL OF RISK: in terms of hazard severity and probability of occurrence - Severity: catastrophic, critical, marginal, negligible - Probability: frequent, probable, possible, remote, improbable ACCEPTANCE OF RISK: accept no unnecessary risk WEIGHT/AMOUNT OF BENFITS VS RISK: accept risk only when benefits outweigh risks Example: Flight Instructor turns off fuel selector/fuel shutoff in flight in a single engine airplane to simulate loss of engine power

18. Risk Vs Benefits Analysis WHAT IS THE HAZARD? WHAT IS LEVEL OF RISK IN TERMS OF SEVERITY AND PROBABILITY OF HAZARD? - Severity: catastrophic, critical, marginal, negligible - Probability: frequent, probable, possible, remote, improbable IS THERE UNNECESSARY RISK? WHAT IS BENEFIT? DOES THE BENEFIT OUTWEIGH THE RISK?

19. Operational Risk Management Elements

20. Develop Action Plan: T-E-A-M Transfer: can the risk be transferred or shared? Eliminate: can the risk be eliminated? Accept: can the risk be accepted? (See Risk Vs. Benefits Analysis) Mitigate: can the risk be mitigated? (Reduced to an acceptable level) Example: Planned IFR flight- lowest MEA's along route will be in IMC with forecast temperatures aloft at or below freezing

21. WHAT IS THE RISK? CAN THE RISK BE TRANSFERRED OR SHARED? CAN THE RISK BE ELIMINATED? CAN THE RISK BE ACCEPTED? CAN THE RISK BE MITIGATED? Develop Action Plan: T-E-A-M

22. Operational Risk Management Elements

23. EXECUTE- Task Management (TM) Task Management is an integral part of the EXECUTE phase of ORM. Task: function performed by human as opposed to machine or system Task Management (TM): process by which pilots manage concurrent tasks required to safely and efficiently operate a modern aircraft. TM entails: - initiation of new tasks - monitoring on-going tasks - prioritization of tasks - allocation of resources based on priority - resumption of interrupted tasks - completion or elimination of tasks Critical Phases of Flight for TM: - pre flight preparation & planning - before take off/departure preparation - take off & initial departure - descent/approach preparation - initial approach/pattern entry phase - go around/missed approach

24. EXECUTE- Task Management (TM) Task Management affected by: - weather - stress - Air Traffic Control - aircraft condition - information/data overload Task Saturation: inability to perform task management due to one or more of factors above PRIORITZATION OF TASKS IS KEY TO AVOIDING TASK SATURATION! AVIATE NAVIGATE COMMUNICATE

25. POST FLIGHT: "Lessons Learned" Successful Operational Risk Management does not end when the flight is over! After each flight the pilot should conduct a "lessons learned" review of the following: - What did I do well/right? - What did I do poorly/wrong? - Did I identify any hazards? - Were the hazards analyzed and the risks assessed? - Did I develop an action plan based on the risk assessment? - Did I execute my action plan? Was that plan successful? - Were there any occurrences which should be reported via an Air Safety or Hazard Report?

26. REMEMBER FOUR BASIC PRINCIPLES OF ORM ACCEPT NO UNNECESSARY RISK MAKE RISK DECISIONS AT APPROPRIATE LEVEL ACCEPT RISK ONLY WHEN BENEFITS OUTWEIGH POTENTIAL OUTCOME INTEGRATE ORM INTO ALL PHASES OF FLIGHT

27. REFERENCES - Aviation Instructor Handbook (FAA-H-8083-9A) - FAA System Safety Handbook - CGAP Safety Management System Manual - CGAP EA-500 Training Manual - Industry Standard Practices for Risk Management - Industry Standard Practices for Operating Excellence (Six Sigma)