Confessions of a Senior air accident investigator

ISSN 2369-873X

22 July 2015
Posted by: Mike Cunningham

There is an old Scottish proverb, “Confession is good for the soul.” I’m very proud of my Scottish ancestry and I’m a passionate aviation safety advocate. Therefore it is my duty to confess a few lost opportunities to advance aviation safety I experienced early in my career. But you will have to read to the end of this post in order to hear my confession. It may also be one that many active, and former training pilots can relate to.

Every year, millions of successful landings occur on Canadian runways. However, there is a risk that accidents can occur during the landing. These accidents include runway overruns, runway excursions, landings short of the runway, and tail strikes. In Canada, from 2009 to 2013, Canadian-registered aircraft were involved in an average of 150 approach-and-landing accidents (ALAs) every year. For this reason, ALAs have been on the Transportation Safety Board of Canada’s (TSB’s) Watchlist since 2010.

Figure 1. First Air accident site
Picture of the First Air accident site

One of the most recent ALAs in Canada involved a First Air Boeing 737 at Resolute Bay, Nunavut, on 20 August 2011. The fact that the flight crew did not recognize and correct an unstable approach was a contributing factor in this tragic accident. Stable approaches significantly increase the chances of a safe landing. The TSB investigation report highlighted the scope of this issue by referencing the research being conducted by the Flight Safety Foundation (FSF) in their Go-around Decision Making and Execution Project initiated in 2011. Their research indicates that 3.5% to 4% of approaches are unstable. Of these, 97% are continued to a landing, with only 3% resulting in a go-around (GA). Unstable approaches are the number 1 cause of runway excursions. The research suggests that if GA policies were effective in even 50% of the cases, the runway excursion rate would be reduced by 10 to 18%.

Figure 2. Air France accident site
Picture of the Air France accident site

The Go-around Decision Making and Execution Project furthered its research into why this is a global problem by surveying aviation companies and more than 2,300 commercial pilots. The results from this extensive FSF project are expected to be released in the fall of 2015. Areas of concern being explored include situational awareness, pilot knowledge, training, previous GA experience, crew interactions and understanding of GA decision making protocols.

The importance of go-around decision making has been identified in many TSB reports, including the investigation of the Air France Runway Overrun (A05H0002) that occurred 02 August 2005 at Toronto. The FSF project reflects the same concerns regarding pilot decision making in rapidly changing weather conditions identified in this investigation and resulting in a TSB recommendation (A07-03).

Section 4.2.2 of the Safety Action Required section of the Air France report notes:

The Board believes that the ability to capture and interpret cues that are essential in the decision-to-land process is inadequate, especially when the cues are ambiguous or not immediately compelling. Consequently, pilots will continue to land in deteriorating weather once the landing decision has been made, in spite of cues that indicate that a go-around or balked approach should be executed. Therefore, the Board recommends that: The Department of Transport (TC) mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather. A07-03

The question that begs to be asked for me is; if Go-around Decision Making and Execution is a significant problem with well-trained airline pilots, how does it factor into the day-to-day line operations of the smaller commuter and air taxi operators?

In 2015, the TSB began an in-depth Safety Issues Investigation (SII) into the risks that persist in air taxi operations across Canada. Over the past 10 years, the TSB has repeatedly drawn attention to critical safety issues that contribute to air taxi accidents such as crew adaptations from standard operating procedures, and pilot decision-making. Many of these accidents have occurred in the approach-and-landing phase.

Figure 3. Global express
accident site
Picture of the Global express accident site

All Canadian pilots begin training to meet the same Transport Canada flight test standards and GA training is defined in these standards. As pilots progress throughout their careers, GAs should be covered in every aircraft proficiency course they take. Since the research shows that, in fact, GA compliance is inadequate, perhaps all levels of pilot training need some adjustment, especially when it comes to the importance and philosophy of conducting proper GAs.

For 10 years, early in my career, I was a very active senior training pilot. I trained many commercial pilots, and functioned as a flight test examiner. I always believed in teaching the proper techniques to pilots and flight instructor candidates. After all, training pilots, at every aviation level, are responsible for laying a strong foundation for safe airmanship and decision making.

Here comes my confession! I have slipped up a few times during my many years instructing! Training pilots, at all levels, frequently encounter many approaches where stable approach criteria may be exceeded, technically requiring a GA. But frequently in the interest of time, money, and in weather conditions we consider manageable, we often allow student pilots to salvage the approach. Or even worse, we might occasionally take control of the aircraft in an attempt to show them just how the experienced guys do it. Yes, I am embarrassed to say I have done that! And, by doing it, I have given my students the impression that salvaging the approach and ignoring the stable approach criteria when it is convenient, is OK. If other training and senior pilots do the same thing, then young pilots will come to the airlines with this mindset about GAs. It is an issue that safety boards and the researchers must find a way to shift in a positive direction. There, I feel better now!

Image of Mike Cunningham

Mike Cunningham has over 30 years of experience in civil aviation and 18 years of experience as a Senior Operational Investigator with the Transportation Safety Board of Canada (TSB). Originally hired when the TSB was expanding its human factors investigation capabilities, Mike has a Bachelor of Science with a major in psychology as well as an Airline Transport Pilot License. Mike is a serious fan of lighthouses as his grandfather was the light keeper at the Yarmouth, Nova Scotia, lighthouse for 30 years. He still spends some of his volunteer time helping preserve the beautiful historic site, which is celebrating its 175th anniversary.

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