Beyond the FRAT: Understanding risk management

Editor’s Note: Jack Schonely recently retired after a 31-year career with the Los Angeles Police Department, including 18 years with its Air Support Division (ASD) as a tactical flight officer, pilot, and flight instructor. In this first of a two-part series, he and the ASD’s former safety officer, Mark Bolanos, recall some experiences that caused Schonely to rethink his personal approach to risk management.

Jack Schonely: Have you ever met a pilot who didn’t believe he or she was a safe pilot? I know I haven’t met one. All of us have learned about safety from day one of our aviation training, whether it was from the military, the private sector, or a certified flight instructor at our units.

The LAPD's Hooper Heliport is the site of regular fly-ins. Early in their professional relationship, the authors clashed over the best way to coordinate one such event. Skip Robinson Photo
The LAPD’s Hooper Heliport is the site of regular fly-ins. Early in their professional relationship, the authors clashed over the best way to coordinate one such event. Skip Robinson Photo
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Basic safety policies and procedures are a big part of the process of becoming a certified pilot. These later become part of our everyday lives as pilots: doing a good pre-flight of the aircraft, completing a flight risk analysis tool (FRAT), checking weather, checking notices to airmen, examining the maintenance books, checking performance, making good “go/no-go decisions,” and discussing safety with our co-workers.

All of that is great, but many pilots may be unaware of additional safety measures and techniques that are out there unless they have a good safety officer sharing the valuable information and at times even insisting that something change in the name of safety.

I believed that I was a safe pilot. No, I believed that I was a very safe pilot for many years. It wasn’t until a very smart and dedicated safety officer at my unit, Mark Bolanos, began sharing information with me that I learned about some of these additional safety tools, including safety management systems (SMS) and in particular risk analysis.

To be honest, some of the things he would point out seemed ridiculous to me. They seemed very minor in the big picture and at times I dismissed them or we would have a verbal conflict of opinions. In hindsight, I feel really stupid for questioning the things Mark was sharing. He was telling me things that he believed were important to keep me, and everyone else, as safe as possible without inhibiting whatever we were doing. Unbeknownst to me, he was managing risk.

Luckily, I quickly realized that Mark knew much more about safety than I did, and I began to change. This change did not occur overnight nor did it occur from a single incident, but it did occur and I became a much safer pilot because of it.

Mark and I believe that journey is worth sharing so that all pilots can be more open-minded and look at their jobs in a different way. We are going to share a few operations that we worked on together and look at them from two points of view — the pilot side and the safety officer side — and demonstrate why we all need to improve on everyday risk analysis beyond the FRAT.

Mark Bolanos: “In flying … carelessness and overconfidence are usually far more dangerous than deliberately accepted risks.”

This quote adorns a wall at our heliport. We see it every day before we walk out to our aircraft to fly our next mission. Unfortunately, I doubt most of our pilots understand it, let alone live it; I know I didn’t.

An aerial view of the AON building in downtown L.A., a 62-story skyscraper with an approved helipad on its rooftop. Photo courtesy of Mark Bolanos
An aerial view of the AON building in downtown L.A., a 62-story skyscraper with an approved helipad on its rooftop. Photo courtesy of Mark Bolanos

Like Jack, I thought I was a “safe” pilot. I didn’t think I was careless or overconfident. I had learned about safety during flight training from very competent, certified flight instructors. It wasn’t until I attended advanced safety training that I realized how much I really didn’t know about safety, risk, or risk management. Today, I still don’t believe I am careless or overconfident, but I know I am better at accepting risk!

The more I learned about safety and risk management, the more I wanted to share with my peers. Unfortunately, I knew it was a going to be a challenge. I was the new safety officer and one of my previous attempts at providing safety-related input didn’t go too well. Jack and I got along but we had had a pretty big blow-out during a safety-related discussion.

Our safety discussion was in preparation for an upcoming fly-in. We needed to paint symbols on our flight deck to identify temporary landing zones (LZs). We discussed painting large shapes on our flight deck so that landing pilots could quickly and easily identify the correct LZ when directed by the
tower operator.

I was concerned about a pilot mishearing landing instructions and attempting to land at the wrong LZ. Let’s just say my suggestion that all of the symbols be different shapes, regardless of the location on the flight deck, was not well received. This event did not deter me in my efforts to share safety information with my peers and supervisors.

SWAT has a Request

Schonely: As the lead for the cadre of pilots who fly SWAT missions, I was approached by a team leader from SWAT about a training evolution they were planning. They were requesting a “SIP mission,” SWAT Insertion Procedure, in which four SWAT operators stand on the skids
of an Airbus H125 and are transported to a rooftop destination for insertion.

This is something our unit has practiced for many years on various airframes, so this was not an unusual request. As a pilot, my first reaction was, “No problem, let’s do it.” My first reaction was not the correct reaction at all. It’s the “cop” reaction, not the reaction of an aviator. Fortunately, Mark had taught me to slow down, get all of the details, complete a risk analysis, and then decide if we would be able to support the training mission.

The details of the training mission were very simple to understand. SWAT was requesting two aircraft to transport eight operators from the department heliport to the rooftop helipad of the AON building in downtown Los Angeles. The AON building is a 62-story skyscraper with an approved helipad at 858 feet above ground level, and is a quick three-minute flight from our base.

The operators would depart the aircraft, enter the building, and deal with a simulated hostage situation several floors down. After the drop-off we would be done, so it was a basic SIP transportation mission, right? Now was the time for the flight leader and the safety officer to get together and decide whether we could safely support the request.

Bolanos: Although our unit had flown this mission numerous times, I wanted to look at it from a new paradigm. I had received formal risk management training from the United States Navy when I attended the Aviation Safety Officer School in Pensacola. I wanted to incorporate what I had learned about risk management into our preparation for the training to ensure we could accomplish the mission with a minimum likelihood of loss.

The purpose of risk management is to identify and mitigate hazards — anything that might cause harm or jeopardize mission success. The objective was to reduce the likelihood of a negative occurrence and/or the severity of the occurrence.

I learned there are four basic principles of risk management:

A.  Accept risk when benefits outweigh the cost

B.  Accept no unnecessary risk

C.  Anticipate and manage risk by planning

D.  Make risk decisions at the right level

While most pilots already adhere to basic safety policies and procedures, a good safety officer can give them new tools for evaluating and managing risk. Skip Robinson Photo
While most pilots already adhere to basic safety policies and procedures, a good safety officer can give them new tools for evaluating and managing risk. Skip Robinson Photo

The risk management process consists of five basic steps. The first two steps include the risk assessment part of risk management and significantly improve awareness and understanding. The remaining steps provide the risk mitigation component of risk management.

The five steps:

1. Identify the hazards

2.  Assess the hazards

3.  Make risk decisions

4. Implement controls

5.  Supervise

I recommended we analyze the mission in phases and apply the process in sequence. We broke the mission into four phases:

1. Passenger loading

2. Flight

3. Passenger off loading

4. Return flight

During each phase of the mission, we attempted to identify any and all hazards associated with people involved (man), equipment (machine), environment (medium), purpose of the flight (mission), and policies and procedures (management).

Some of the things we considered:

1. Man:

a. Air crew: selection, performance, personal factors, training, qualifications, currency,  proficiency, fatigue

b. SWAT: training, currency, proficiency, role

2.  Machine:

a. Aircraft selection, design, ergonomics, maintenance time, weight and balance, holding straps, door configuration, seat  cushions

b. SWAT harnesses, weapons, loose equipment, radio communications

3. Medium:

a. Weather, operational, departure area, landing  area, suitability, barriers, approach, terrain, takeoff

4. Mission:

a. Type of mission or purpose of the operation

5.  Management:

a. Policies, procedures, allocation of resources, standards

Schonely: If Mark had just provided me with that risk analysis outline and bullet points, I’m not sure how much impact that would have had on me. What he actually did was explain to me that risk analysis is a mindset and something that is easily applied to any situation that has hazards, which is everything we do. The outline just guides you through a process of identifying hazards and addressing them one by one.

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Prior to learning more on this topic from Mark, I probably would have looked at the SWAT SIP mission request and thought it was an easy transport mission from our home base to a rooftop helipad and not given much thought to the AON building helipad. I had landed there before in a Bell 206 and did not recall anything unusual about this approved helipad. But I was open-minded to Mark’s information and it was obvious to me that we had to do an on-site survey, or recon, of the AON pad. Mark was observing a change in me.

During their recon of the AON rooftop helipad, the authors realized that the elevated netting and lights posed the risk of a tail strike if pilots came in too fast. Photo courtesy of Jack Schonely.
During their recon of the AON rooftop helipad, the authors realized that the elevated netting and lights posed the risk of a tail strike if pilots came in too fast. Photo courtesy of Jack Schonely.

Mark and I flew an H125 helicopter to the AON building to begin our recon. Even though we had both flown over and around this building hundreds of times, we immediately noticed some significant issues with the pad and its surroundings. There were lots of obstacles on that rooftop that included antennas, air conditioning units, and window washing equipment. Our mindset of what we were doing gave us both a completely different view of the helipad from past experiences. After a thorough high and low recon I flew the approach into the pad and landed.

The plan was that we would each get out and take a look around, identifying hazards and snapping photos for a future safety brief. As I walked around the rooftop a few things popped out at me. First of all, this pad was not very big. As I made my way towards the rear I was stunned to see that the safety netting around the pad was not flush to the pad. It was slightly elevated and more importantly the pad lights were attached to the outside support of the netting and were much higher than I expected. This was a significant hazard that had always been there, but one that I never noticed before. Mark was able to see the same hazards before we departed the pad and returned to the heliport to start a thorough risk analysis.

We sat down and started to list all of the hazards we had observed — and they were numerous. Most of these hazards were low- to medium-risk and were easily mitigated to an acceptable level for a training mission. Even the elevated netting with the pad lights was mitigated to an acceptable level of risk. The mitigation was that both pilots flying the training mission would complete a recon landing prior to the training. They would fly a flat, stable, powered-up final approach to touchdown so the tail would not dip towards the obstacle and the landing would be as far forward on the pad as possible. These were very simple but effective mitigations.

What if we had not completed the recon of that pad? Something as simple as dipping the tail a bit just prior to landing on a pad 62 stories up could have been catastrophic. Mark was teaching me valuable lessons that would affect how I looked at everything I did as a pilot and even other activities outside of work.

Our team effort of a very thorough risk analysis paid off with an outstanding training day with no unforeseen circumstances. During the debrief for the event, we were all very happy with how it went and were thrilled that we were able to support the SWAT mission with confidence. That confidence was a direct result of planning,
a good reconnaissance, and a thorough risk analysis — beyond the FRAT.

One thought on “Beyond the FRAT: Understanding risk management

  1. Excellent article! Bringing it all together on the example of one particular mission.

    “In flying … carelessness and overconfidence are usually far more dangerous than deliberately accepted risks.” So true. Only that in some countries the judiciary takes on opposite view.

    Carelessness is the mark of man slaughter. Having deliberately accepted risk is used to qualify the same mishap as premeditated murder.

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