Risk Analysis Using the PAVE Checklist  Key findings of the NTSB final report of the Mooney accident, highlighted in yellow, emphasized the pilot's loss of control of the  aircraft and inadequate in-flight planning. These facts accurately described the final events of the flight leading to the loss of control.  In fact, conventional accident analysis classifies accidents such as this one as pilot error due to loss of control.  The NTSB report on the Mooney accident reviews the accident facts to arrive at its probable-cause finding. Yet, there is more to learn  about the root causality of the accident by examining the pilot’s reaction to events during the flight using the PAVE acronym from  Chapter 1.  The pilot knew about the vacuum pump failure and the instrument meteorological conditions (IMC) ahead of him. The faulty  equipment generated an aircraft, or "A" hazard and IMC generated an environment or “V” hazard. The combination of those two$_{ }$ hazards created an unacceptable risk once the pilot decided to penetrate the weather. In addition, it is possible that the pilot’s desire to$_{ }$ get to his destination created an external pressure, or “E” hazard. Finally, the pilot’s assumption that he could control the aircraft with  critical in s truments inoperative created a pilot, or “P” hazard. The risk assessment matrix [ Figure 10-2 ],  indicates  catastrophic consequences were possible from loss of control in IMC, and the likelihood of loss of control after a vacuum pump  failure, was at least occasional or even probable. Thus, the overall risk presented was high or red and needed mitigation of some kind.  The pilot’s most effective mitigation may have been to divert and land while still in visual  meteorological $_{ }$conditions (VMC). Why$_{ }$ was the pilot unable to practice effective risk management on this flight? Lack of risk management training may have created an  inability to cope with a difficult situation.  Instructors have a role and a responsibility to help pilots obtain the necessary risk management training and to adopt a safety culture  that embraces risk management and mitigation of risk. The instructor’s role in risk management should be incorporated at all levels of  training, from a new pilot with little experience to a multi-thousand-hour pilot taking recurrent training.  The importance of risk management suggests that it should be taught at the very start of flight training and should be integrated into  any actual flight training, rather than taught as a separate subject. However, it will be even more effective if the learner receives  ground instruction on this topic prior to the first flight lesson. This preliminary instruction should also be part of any formal ground  school.  Risk management activity and discussion should be included in all preflight and postflight briefings. Learners should be encouraged  to participate and even lead such discussions as their experience increases.  10-2 When to Teach Risk Management  Figure 10-2.  This risk matrix can be used for almost any operation by assigning likelihood and severity. In the case presented, the  likelihood of occasional and the severity as catastrophic falls in the high-risk area. 