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Why are unstable approaches continued?. Ewout Hiltermann. IASS October 2013. 2. Recommendations . Aircraft operators: Use flight data to analyse event flights with the crew for organizational learning. Aviation industry:
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Why are unstable approaches continued? Ewout Hiltermann IASS October 2013
Recommendations • Aircraft operators: Use flight data to analyse event flights with the crew for organizational learning. • Aviation industry: Develop and implement new technical and procedural solutions to effectively control this risk. 3
What’s the Problem? 4 Landing accidents are most common accidents Relation between unstable approaches and landing accidents ± 1000 unstable approaches are flown every day Only 3 % of unstable approaches result in go-around Why is risk control inadequate?
Flight Data Monitoring (FDM) 5 • Data validation shows: • Data have no context • The key question remains:why?
Our Method 6 • Trigger events in flight data • Assessment of events • Decision by Safety Manager • Flight analysis with crew (‘Flight Replay’) • Organizational learning
Success factors 7 • Just culture • Staff of Flight Safety dept are gatekeeper • Attendance of flight crew is rostered • Confidential setting, Chief Pilot / Instructor involved • Pilot unions involved to monitor the process • Open atmosphere
Agreement between unions and company Flight analysis with crew is intended exclusively as a learning exercise for both the crew and KLM Cityhopper. The flight analysis will have no adverse consequences whatsoever for the crew. 8
What did we learn? Some human factors 10 • Expectation to bring the aircraft to the runway • Perceived pressure by punctuality objective • Decision gates IMC/VMC, grey area • Goal fixation and continuation bias • Misperception of height above runway • Landing perceived safer than go-around
Human Factors overview • Expectation to bring the aircraft to the runway • Perceived pressure by punctuality objective • Decision gates IMC/VMC, grey area • Goal fixation and continuation bias • Misperception of height above runway • Landing perceived safer than go-around 11
Conclusions 12 • Risk control is generally inadequate because: • There is no ‘unstable approach warning system’ • Human factors preclude timely crew action • International recommendations are ineffective
Recommendations • Aircraft operators: Use flight data to analyse event flights with the crew for organizational learning. • Aviation industry: Develop and implement new technical and procedural solutions to effectively control this risk. 13