Chapter 1: Risk Management and Single-Pilot Resource Management  Aviation Instructor's Handbook (FAA-H-8 083-9)  Introduction  1-1 This chapter discusses safety risk management in the aviation community, looking at it as preemptive, rather than reactive. The  principles of risk management and the tools for teaching risk management in the flight training environment are addressed in Chapter  9, Techniques of Flight Instruction.  This scenario underscores the need for safety risk management at all levels of aviation. Safety risk management, a formal system of  hazard identification, assessment, and mitigation, is essential in keeping risk at acceptable levels. Part of this process is selecting the  appropriate controls to mitigate the risk of the identified hazard. The primary objective of risk management is accident prevention,  which is achieved by proactively identifying, assessing, and eliminating or mitigating safety-related hazards to acceptable levels.  While a definite answer to the question of what happened remains a matter of speculation, professional mechanics heed warning signs  of potential problems. The combination of a lengthy inspection, numerous technicians, an overworked supervisor, a poor checklist,  and vague communication raise a red flag of caution.  Complacency—an insidious and hard-to-identify attitude. Each of the mechanics involved in the incident thought someone else had  inspected the throttle rod-end. The IA signed off the annual inspection after asking the mechanics about the items on the checklist,  making frequent visits to the airplane, inspecting some of the various items, and deciding that was good enough. Complacency  crippled the mechanics’ quality of work by removing any thoughts of double-checking each other’s work.  Checklist misuse—Perhaps the throttle rod-end had been disconnected for maintenance after the IA had signed off the  control inspection and marked that item as complete on the maintenan c e checklist. In that case, a discrepancy should have been entered onto the discrepancy sheet stating, “reconnect and safety throttle rod-end.”$_{ }$ Lack of responsibility—no one took responsibility for the entire inspection. The chances of something being overlooked increase with  an increase in the number of mechanics involved in an inspection. The responsible person is removed from the actual procedure. The  learner remembers hearing the IA ask one of the engine mechanics about the throttle. However, the question was vague, the answer  was vague, and the rod-end was not safetied.  ⦁ $_{Complacency }$ ⦁ $_{Checklist misuse }$ ⦁ $_{Lack of responsibility }$ Three deficient areas in th is annual inspection were identified by a round-tab le discussion group of aircraft and powerplant (A&P)  mechanics and the learner. These areas were:  After the inspection, the engine had been run-up according to the usual post-inspection procedures. The learner and instructor had  flown the airplane for a half-hour familiarization flight. The next day’s engine start resulted in a runaway engine with the apparent  cause due to the lack of the throttle rod-end hardware being safetied.  The previous day, the annual inspection had been signed off after a lengthy inspection by a local facility. Several mechanics had been  involved in the inspection, including the owner/learner who had installed a headliner. The mechanic with the Inspection Authorization  (IA) who signed off the annual was supervising several annuals, so most of the maintenance was performed by other mechanics.  “What I want to know,” Lenore said, “is how this happened at all. The annual inspection was signed off yesterday.”  Ten minutes later, they had removed the cowling from the airplane. A quick engine check gave them the answer. The throttle rod-end  was not connected to the carburetor arm—no bolt, no nut, just air between the rod-end and the arm. Jennifer looked at Lenore. “What  if this had happened in flight?”$_{ }$ Both Jennifer and Lenore grabbed the mixture and pulled. The engine went from a deafenin g roar to silence . They looked at ea ch  other. “What happened?” asked Jennifer. “I don’t know. Let’s check the engine,” Lenore said.  “Pull the throttle back!” Lenore, a  f light  instructor , ordered the learner, Jennifer, as the revolutions per minute  (rpm) climbed past past 2,000 on engine start. “I did, I did!” 