Premium on Safety - Issue 30, 2018 - 1

ISSUE 30 FALL 2018


Best Practices: My Director and Chief 02
Pilot went to IS-BAO
Lessons Learned: Low, Tight, and Perilous 06
Trainable Moments: Into the Belly 08
ASI message: The Latest Accident Reports 09
Future Tech: Virtual Reality 10


Committing to the Go-Around

Turns out there's a problem with go around decision-making in aviation
I spent many hours in the passenger
seat during road trips this summer. It was
a sobering chance to observe in detail
the 'cockpit' activities of drivers in other
cars. It's hard these days to go more than
a few minutes without seeing a driver
manipulating a cellphone. Many are in late
model cars with built-in hands-free features drivers are choosing
to ignore. The drivers don't look like wild-eyed risk junkies and
most aren't teens. They look, well, like any of us. Some of them are
likely parents who've admonished their kids to 'never ever' text and
drive, or company officers who've peddled that theme to staffs. It's
not that they don't know they are flirting with a high-consequence
(but relatively low-frequency) threat, or aren't aware of the laws,
technologies and campaigns fielded to adjust behaviors. Those
many, many drivers have simply rationalized all of that away in
favor of whatever personal agenda they are confronting right now
because, after all, if they don't cause a crash-and they probably
won't-nobody's going to review their behavior. They've been
conditioned to expect, like so many times before, that they'll get
away with it.
An eerily similar-sounding context pours from the pages of the
2017 Flight Safety Foundation-commissioned report on
Go-Around Decision Making. There's an ample body of evidence
that over 80 percent of runway excursions could have been avoided
by a timely decision to go around. Most operators have policies
that direct a go-around if aircraft are not within stabilized approach
criteria, and there have been awareness campaigns aplenty
that earn vocal support from influential aviators and industry
leaders. Many operators have addressed and lowered their rate
of unstable approaches, yet here we are; consistently continuing
more than 95 percent of approaches that do become unstable to

landings anyway, rather than executing the 'compulsory' go-around.
Fortunately, most (though not all) are survived.
The report summarizes that pilots making such landings from
unstable approaches are minimizing the objective threats in their
personal risk assessment. Further, their decision-making process
isn't being helped by crew norms and processes, and there is
no real disincentive to land from an unstable approach coming
from their employer (or anywhere). The report calls this "a recipe
for the normalization of deviance." Sound familiar? Should we
be surprised that runway excursion rates have been flat-or that
distracted driving incidents are on the rise-despite years of trying
to lower them?
The most forward-thinking operators today view the stabilized
approach as just one step, rather than a panacea, to prevent
runway excursions. They are looking hard at how often and why
their operation continues unstable approaches to landing, and are
finding constructive, consistent and non-punitive ways to address
these dangerous anomalies. This approach toward changing pilot
habits holds great promise to lower the runway excursion risk and
there's a name for it: safety leadership.
Fly smart and fly safe.

Paul Ratté
Director of Aviation Safety Programs, USAIG

Table of Contents for the Digital Edition of Premium on Safety - Issue 30, 2018