“Robert Novell’s Third Dimension Blog”

Good Morning and welcome to a new look for the Monday blog. Each Monday I will alternate between my articles on “Aviation Wisdom From the Past” and an article on aviation safety. This week I want to showcase an article from the Flight Safety Foundation that will help each of us rationalize why we need to be more cautious on accepting less than optimum performance by our aircraft or ourselves.

Enjoy………………………

Failure to Mitigate

Studying the psychology of decision making during unstable approaches and why go-around policies are ineffective……… (Written by J Martin Smith, David W. Jamieson, and William F. Curtiss of the Flight Safety Foundation)

The Flight Safety Foundation has analyzed the past 16 years of aircraft accident data and found that the most common type of accident is the runway excursion, which accounts for 33 percent of all aircraft accidents.¹ The highest risk factor for runway excursions is the unstable approach.² Unstable approaches occur on 3.5 to 4.0 percent of all approaches, but only 3 percent of these unstable approaches result in a go-around being called in the cockpit: almost all aircrew in this state — 97 percent — continue to land. It can be argued, therefore, that the almost complete failure to call go-arounds as a preventive mitigation of the risk of continuing to fly approaches that are unstable constitutes the number one cause of runway excursions, and therefore of approach and landing accidents. If our go-around policies were effective even 50 percent of the time, the industry accident rate would be reduced 10 to 18 percent. There is no other single decision, or procedure, beyond calling the go-around according to SOPs that could have as significant an effect in reducing our accident rate. Why, then, is compliance so poor?

The Foundation in 2011 initiated a Go-around Decision Making and Execution Project designed to mitigate runway excursions caused by unstable approaches by achieving a high level of pilot compliance with go-around policies. This project expects enhanced compliance to result from answering the research question, “Why are go-around decisions, that should be made according to policy, actually not being made during so many unstable approaches?” and then making recommendations based on the findings. The project, which is ongoing, also will examine the psychosocial contributions behind flight operations management’s role in the phenomenon, as well as the risks associated with flying the go-around maneuver itself.

In a series of articles to be published in AeroSafety World over the course of this year, we will describe the latest results of the project’s work, which to date includes a worldwide pilot survey conducted on behalf of the Foundation by The Presage Group. The survey is designed to understand the psychology of decisions to go around rather than to continue to fly unstable approaches.

This first article describes a novel strategy for understanding this psychology, which we call the Dynamic Situational Awareness Model (DSAM), that we successfully have applied in several other operational contexts to help mitigate risk and increase compliance. The remaining articles will include the results of two experiments conducted within the pilot survey in which we assessed factors leading up to a decision. The experiments attempted to answer such questions as: “Are go-arounds associated more with some kinds of instabilities than with others?”; “What sorts of pilot characteristics, if any, are associated with go-around decision making?”; “What information did pilots solicit to assess risk prior to making their decisions?”; “What is the implicit incentive structure for flying go-arounds versus continuing the unstable approach that pilots perceive in their organization’s culture?”; “What is the nature of the crew interactions that support compliance with go-around policies?”; “In hindsight, to what factors do pilots attribute their decisions to go around or continue with an unstable approach, and do these reflect all the experiences that were actually inputs to their decisions?”; “What are the true key drivers of their risk assessments and decisions?”; “Do pilots experience any post-decisional regret for non-compliance with go-around decision making protocols?”; “Do pilots accept the basic definitions set by their organizations for what defines an unstable condition, as well as the standard operating procedures (SOPs) their organizations have set out to handle them?”; and “Apart from their company’s definitions, beyond what thresholds of instability on key flight parameters do pilots personally define themselves to be in an unstable state that warrants a go-around decision?”

By understanding more completely the answers to these questions, our goal is to bring new thinking to bear on the topic of non-compliance with unstable approach SOPs, and to offer ideas about how to mitigate these risks based on a better alignment of pilot psychology with company policy.

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Have a good week and thanks for letting the 3DB be a part of your routine. Fly safe/be safe.

Robert Novell

March 24, 2014