Unusual Attitudes: The Matrix and Me
A two-man team from Oklahoma City was in town last month with the “live” portion of the FAA’s designated pilot examiner renewal seminar. Half of the mandatory training happens online, but we still get eight hours in one of those hotel meeting rooms; if the air conditioning is cold enough and the coffee strong and plentiful enough, most examiners remain at least semi-conscious through endless PowerPoint slides — mostly paragraphs from handbooks or the regulations.
After too much time with obscure certification issues (a sport pilot with a powered parachute rating who wants to add weight shift control, for example), we got into Risk Management, Aeronautical Decision Making and Single-Pilot Resource Management. The FAA’s in love with this stuff, which I suspect is the product of “academics” who don’t fly airplanes — at least beyond the traffic pattern. Along with cute acronyms like PAVE and DECIDE and I’M SAFE, there’s a nifty matrix to consult before “risking” a flight. It’s kind of an aeronautical Ouija board.
If, for example, you’re concerned about colliding with a hippopotamus on the runway at your destination, you scan horizontally across the top of the chart to determine the “severity” of this encounter — which is certainly “critical,” if not “catastrophic.” Since the runway is in Duluth, the “likelihood” (left vertical) of encountering a hippopotamus is “improbable,” meaning the box where they meet is blue. So go fly — cautiously. But should Duluth Airport be adjacent to a wild-animal sanctuary with a history of escaping hippopotamuses, the likelihood becomes “occasional,” and then you’re in a red box. You should probably land somewhere else — unless it’s January and the herd has migrated south.
This is a ridiculous example of what I think is a ridiculous idea — the matrix certainly, and maybe even Risk Management training in general. Identifying the severity of a risk — thunderstorms, ice, fatigue, limited fuel capacity — is a no-brainer. But determining the likelihood of it becoming an issue on your flight is an individual call that requires common sense. And I don’t think that you can teach or test common sense.
We also spent some time with an NTSB accident report of a Bonanza that crashed on takeoff, killing the pilot and severely injuring three passengers. Extensive damage to the cockpit prevented investigators from identifying the position of most switches and selectors. With evidence of plenty of fuel at the crash site but none in the fuel lines, they concluded that the pilot-owner was unfamiliar with the modified fuel system and had inadvertently run a tank dry. We were supposed to determine if the use of Risk Management tools could have prevented the crash. Could he have averted the disastrous consequences by first assessing his competency and knowledge of the airplane, his experience, his mental, emotional and physical health, his attitude? Did he ponder his history of decision making?
Another pilot who flew with him reported he was often “really hot” on approaches and didn’t seem to be in control of the airplane. Nor was he familiar with aircraft systems; more than once he inadvertently ran fuel tanks dry in flight or had engine failures on the runway after touchdown. On another flight he was unaware that the autopilot had disengaged until a passenger remarked they were in a climbing turn and, when asked to demonstrate a coupled instrument approach, he was unable to configure the autopilot.
Although his most recent medical application listed no medications or medical history, hospital records from a recent shoulder operation listed mild obesity, high blood pressure, irregular heartbeat, elevated cholesterol, depression and anxiety with panic attacks. He was taking at least eight prescription medications and using a CPAP (continuous positive airway pressure) device at night for sleeping.
So, sure, by using Risk Management tools he’d realize he wasn’t fit to fly. But would a guy so deficient in common sense have even considered Risk Management, Aeronautical Decision Making or how to construct a Risk Matrix? I think not.
The report resonated, because I’d made a dead-stick landing at Wright-Patterson Air Force Base some years before in a Bonanza I was flying. In those days it wasn’t uncommon for FAA inspectors to use privately owned airplanes and combine currency flying with the performance of some work function. In this case I was going to Detroit to do DC-3 check rides at the Yankee Air Museum. And I’d flown this airplane enough to be aware (and wary) of its converted and complex fuel system.