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Why are unstable approaches continued?

Explore the prevalence of unstable approaches leading to landing accidents in aviation and the inadequacies in risk control mechanisms. Learn about the role of human factors and recommendations for aircraft operators and the aviation industry to improve safety.

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Why are unstable approaches continued?

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  1. Why are unstable approaches continued? Ewout Hiltermann IASS October 2013

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  3. 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

  4. 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?

  5. Flight Data Monitoring (FDM) 5 • Data validation shows: • Data have no context • The key question remains:why?

  6. Our Method 6 • Trigger events in flight data • Assessment of events • Decision by Safety Manager • Flight analysis with crew (‘Flight Replay’) • Organizational learning

  7. 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

  8. 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

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  10. 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

  11. 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

  12. 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

  13. 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

  14. Questions?

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