Unusual Attitudes: The Matrix and Me

Will the FAA's love affair with Risk Management stand the test of time?

Unusual Attitudes Risk Matrix

Unusual Attitudes Risk Matrix

** The FAA says charts like this one can help determine overall risk by comparing the likelihood of an event and the consequence of that event.**

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.

We left Cincinnati early on a July morning, another newly hired inspector in the right seat for “on-the-job training,” although I’m surprised, in retrospect, that I was training or acting as a role model for anybody. John would go on to become a very big name at FAA headquarters in Washington; I would play out my FAA career — definitely not management material — in the Cincinnati FSDO.

The 1956 G-model Bonanza came from the factory with a 225-horsepower, carbureted engine, holding 80 gallons of fuel and consuming about 11 gph. A previous owner had installed an injected, 260 hp Continental engine and an Osborne conversion with wingtip tanks that provided an additional 20 gallons per side. Now the airplane flew faster and burned more fuel but held 100 gallons, albeit in six separate and relatively small fuel tanks.

Another issue is that the rate of return fuel, always to the left main tank, is quite high — as much as 10 gph. So you start with fuel from the left main tank and then switch to an aux tank or turn the selector to “tip” and use a second selector valve to open the tip line. You run that tank nearly dry (remembering to select the proper gauge, monitor the time and watch the fuel flow) and then go back to the left main. Again, you run that tank down until it’s low enough to accommodate return fuel from the next aux or tip tank you select.

The fuel lines are long, and if you run a tank dry — which is easy to do — you experience a “power interruption” (it quits) and risk vapor lock.

The system was complex enough that somebody had drawn and laminated a fuel selector diagram and checklist, both of which were attached (chained) near the fuel selectors.

After the check rides at YIP we headed back to Cincinnati without refueling — we had left that morning before I could get authorization from my boss to use the government credit card for fuel and, besides, there was plenty in the tanks. It was soft IFR, in and out of clouds, until we broke into the clear just north of Dayton. The outside air temperature was really hot at 6,000 feet, and I was switching tanks constantly, wondering why that left main was refilling so much more quickly than I expected.

We were with Dayton Approach and running off one of the auxes or tips — I don’t remember which. Before I caught the wiggle on the fuel flow gauge and far sooner than I expected, the engine suddenly quit. Switching back to the left main didn’t have any effect, so I pulled out the checklist and asked John to lean over and verify that I had the selectors in the correct position. The left main fuel gauge showed about half full, and John confirmed we were on that tank but still “no joy” on the restart. I told Dayton about our dilemma, and the controller suggested Xenia Greene County Airport, about 12 miles southeast. I told him we would rather take the 12,600-foot runway at Wright-Patterson Air Force Base, directly beneath our wing.

Spiraling down I remarked to John that we’d probably be met with guns and spend the weekend filling out forms. But when we came to a stop on 23R, we were met by friendly and unarmed (I think) guys, who towed us off the runway to base ops. And, because it was an FAA operation, the Bonanza was a “public aircraft,” which eliminated most of the paperwork and bureaucratic hassle.

The Indianapolis FAA airworthiness inspectors who investigated the incident (to avoid any appearance of favoritism) found nothing wrong with the tanks, pumps or injectors. “Vapor lock” was the official verdict — I had run a tank completely dry, it was hot and the engine wouldn’t restart.

But even now I wonder. Vapor lock has always seemed a little like fibromyalgia — the diagnosis given when a doctor runs out of ideas.

My big mistake was my failure to buy fuel at YIP for the return flight that July afternoon. Yeah, we had enough, but I let my worry about getting another reprimand from my manager override what little common sense I had. With a full fuel load I wouldn’t have needed to switch tanks as carefully and as often and probably wouldn’t have run one dry.

Instead of feeling smug about a great emergency landing, I had to remind myself that “truly superior pilots are those who use their superior judgment to avoid those situations where they might have to use their superior skills.”

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