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? 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? 4

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

6. Our Method 1.Trigger events in flight data 2.Assessment of events 3.Decision by Safety Manager 4.Flight analysis with crew (‘Flight Replay’) 5.Organizational learning 6

7. Success factors 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 7

8. 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.

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10. 1.Expectation to bring the aircraft to the runway 2.Perceived pressure by punctuality objective 3.Decision gates IMC/VMC, grey area 4.Goal fixation and continuation bias 5.Misperception of height above runway 6.Landing perceived safer than go-around 10 What did we learn? Some human factors

11. Human Factors overview 1.Expectation to bring the aircraft to the runway 2.Perceived pressure by punctuality objective 3.Decision gates IMC/VMC, grey area 4.Goal fixation and continuation bias 5.Misperception of height above runway 6.Landing perceived safer than go-around 11

12. Conclusions Risk control is generally inadequate because: –There is no ‘unstable approach warning system’ –Human factors preclude timely crew action –International recommendations are ineffective 12

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?