The Human Factor: Unstable Personalities
These situational awareness factors worked together to directly affect a pilot’s perception of and response to risk, with the pilots who tended to continue an unstable approach reporting a much lower assessment of the riskiness and unmanageability of the approach than pilots who tended to go around. These pilots were also more tolerant of deviations from operational limits and procedures, less likely to perform required checklists and calls and less likely to take advantage of other crew members or seek their advice about the best course of action.
The combined effect of these situational awareness factors can lead pilots to adopt a mental model that minimizes the risk of instability and thus reduces their attention to details. Even worse, the pilots who tended to continue an unstable approach were more likely to:
• Feel crew pressure to land and a lack of support for a possible go-around decision.
• Feel uncomfortable when being challenged and in challenging others.
• Feel inhibited about calling a go-around due to the authority structure in the cockpit.
• Report less company support for safety.
• Say there was a lower likelihood they would be reprimanded for landing out of an unstable approach.
The ultimate result of all these factors is a normalization of deviance in which a mode of operation outside of company standard operating procedures and federal aviation regulations is either tolerated, passively supported or even approved by pilots, management and sometimes even regulators. Many years ago, the U.S. Navy discovered a similar phenomenon — that squadrons with a high mishap rate developed a culture in which it was acceptable or even expected that pilots would fly more aggressively than Navy flight regulations allowed. Squadrons that emphasized the importance of operating within the boundaries of the regulations often had years of operations with no mishaps, while the squadrons operating with a normalization of deviance experienced one mishap after another.
Smith and his associates developed nine recommendations based on the findings of their research thus far. These include:
• Redefine stable approach criteria and the height below which a go-around is required if the approach is not stable.
• Include a requirement to state/discuss critical instability factors prior to the approach.
• Institute communications (callouts) that are active rather than passive, for example, “stable/unstable” at 500 feet and at stable approach height.
• Develop automated stable approach monitoring and alerting systems.
As is often the case with human factor issues, the most powerful change will result from each pilot honestly assessing his own approach history and tendency to continue an unstable approach rather than going around when unstable below the stable approach height. Pilots and management of multipilot flight operations should honestly assess their organization’s culture to determine if a normalization of deviance has crept into their operation. It is very easy for management to get so focused on the bottom line that they begin reacting negatively to pilots who “waste” time and fuel by doing a go-around. The best way to fight this tendency is to constantly remind ourselves that the cost of one runway excursion accident can exceed the cost of thousands of go-arounds.
People are much more likely to support standard operating procedures they feel they had a part in developing, while procedures and policies that are handed down from management with no employee input are often seen as unrealistic and resented or ignored. In an ideal world, management would include the company’s pilots in a process of seeking weaknesses in their operation and developing specific limits and callouts. While each individual pilot in a large organization can’t have a say in the final decision, each pilot can have an opportunity to voice his concerns and ideas, and management can use that input to come up with the most reasonable and workable solution. As the next step in their research into this subject, the Flight Safety Foundation is assessing the response of flight operation managers to the fact that 97 percent of unstable approaches do not result in a go-around and what role management feels they might play in improving the situation.