Consider the following spectrum depicting the range of situations encountered by pilots across all flights. (This graphic is from my book, Master Airline Pilot: Applying Human Factors to Reach Peak Performance and Operational Resilience [Taylor & Francis – 2023], Figure 11.3, page 203)
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The left end of the spectrum depicts mundane, familiar, uncomplicated flights. Envision crews flying the same flights, between the same destinations, in unchallenging conditions, day after day. They would apply familiar, proven game plans that require no modification. Flights would go exactly as planned. In relative frequency, these kinds of flights are fairly plentiful in professional aviation.
On the right end of the spectrum, we have extremely rare, unanticipated, and untrained events. Crews would have no prior training, procedures, and little guidance for handling them, either from simulator training, ground training, or flight manuals. To handle these situations, crews would need to diagnose unique problems, innovate solutions, and coordinate specific tasks and roles. In relative frequency, these situations are extremely rare – so rare that most pilots would not encounter even a single event during their careers. These flights, however, tend to be highly consequential and potentially hazardous – for example, US Airways Flight 1549 (2010) – Hudson River landing following dual engine failure while departing from LGA.
Virtually all real-world flights fall within the middle range where crews must continuously modify their plans for unplanned and changing conditions. Starting on the left end and moving to the right, crews must adapt to conditions that are increasingly complex and severe. When flight profiles begin to stray from what was planned, we make instinctive and immediate corrections. A simple example is when a bump of turbulent air causes our right wing to rise. We instinctively counter by deflecting the flight controls to restore wings-level, stabilized flight. On the spectrum, this is described as “plans work with some force”. This strategy reliably works because all game plans include safety margins that accommodate minor deviations.
As we move further to the right, we encounter conditions that cause larger deviations from our planned profile. For example, when a crew finds themselves jammed during an approach, they modify standard procedures by lowering landing gear to bleed off excess energy and reach stabilized approach parameters (note: most configuration profiles start by extending the flaps to an initial/maneuvering setting, then extending the landing gear, then extending the flaps to the landing setting). On the spectrum, this is described as “plans need significant force”. This strategy works because pilot techniques exploit available time and safety margins to mitigate these larger deviations and restore the planned flight profile.
In the middle of the spectrum, we see a range labeled “Crossover Zone”. On the left half of the model, crews apply increasing levels of force to regain acceptable parameters. At some point, however, force becomes ineffective. The original game plan just won’t work. Crews need to modify their game plan, abandon it for a familiar/briefed backup game plan (like executing a go around), or innovate an unplanned backup game plan (like diverting to an airport with a longer runway to better accommodate a landing gear malfunction). The Crossover Zone illustrates how crew decision making doesn’t use either familiar game plans (left side of the spectrum) or unique innovation (the right side of the spectrum). It transitions from forcing the original game plan, to increasing the force needed to make it work, to modifying aspects of the original game plan to preserve desired objectives, and finally, to innovating a unplanned/unbriefed game plan to achieve a desirable outcome.
What makes this Crossover Zone highlights where incident crews make misjudgments that lead to mishaps. Consider a crew that encounters unexpected conditions while maneuvering for final approach and find themselves too fast and steep. They initially apply force (like reducing thrust and extending speed brakes). When these corrections don’t resolve their excess energy problem, they choose to apply more force. They lower landing gear, extend flaps, and steepen their flightpath. They soon realize that their corrections aren’t working. From our informed safety perspective, we clearly see the need to go around and reattempt another approach. From their rushed, quickening, tunnel-focused, in-the-moment perspective, crews often choose to continue and land. A host of biases, rationalizations, and compromises arise. They reason: We are behind schedule and a go-around will make us later – We have plenty of runway to accommodate a long rollout – We aren’t really that fast – The corrections are working and we should be effectively stabilized before landing – We’ll apply more braking after touchdown. It is only after they land that they begin to view their approach with hindsight and conclude that they should have gone around.
When we accurately locate where we fall on the spectrum, we choose the proper blend of force, modification, or innovation to guide our flight toward a successful outcome. When we misjudge and choose to increase force instead of modification or innovation, we succumb to plan continuation bias, tunneled attention, and deteriorating flight profiles. Continuing our unstabilized approach example, after our crew has applied every available correction and technique to force their profile back to stabilized parameters, they seem to resign themselves to the situation. Having done everything they can, they accept the approach failure, land, and attempt to dissipate their excess energy using reverse thrust, wheel braking, and longer runway rollout.
As we move further to the right on our spectrum, we encounter profiles that become unmanageable and unsalvageable. A crew that fails to detect or accept that their game plan is failing might keep applying more force even though no amount of force or pilot action will solve their flight problems. These severe events require us to abandon our original game plan and switch to a safer backup. Using our fast/steep final approach example, forcing the failing game plan would still result in landing too fast and too long and risk a runway excursion. If we recognize this possibility while on final, we would abandon our original game plan (a planned landing) an execute a familiar/trained backup option (a go around). In the heat of the moment, however, mishap crews don’t recognize this hazard.
At the far right end of the spectrum are events that are so rare and unpredictable that they exceed our training and procedural guidance. They require crews to recognize the indications (a loud bang followed by aircraft control difficulty), communicate and agree on problem (aircraft damage within the flap extension mechanism resulting in asymmetric wing lift), make time to deal with the problem (go around, but don’t change the flap settings), form the new game plan (refer to the non-normal checklist), and coordinate unique duties and roles (who flies, who runs the checklist). This severe aircraft damage would adversely affect controllability, so the crew would need to construct a unique game plan and innovate new procedures that compensate for lost or degraded systems while maximizing their chances for a favorable outcome. They might also consult outside experts through their company’s operations center or aircraft manufacturer for advice.
When mishap crews fail, we conclude that if they had just followed procedures, they never would have failed. As safety professionals, we need to accept that just encouraging pilots to “follow procedures” and “go around when your approach is unstabilized” is not enough. When pilots become especially stressed, overloaded, or time-pressured, they lose reasoned decision making. This is especially important since PFs (pilot flying) can become so task saturated and overloaded that they don’t recognize when they succumb to this ill-fated mindset. This is why it is so important for PMs (pilot monitoring) to intervene and direct switching to a safer option. As a profession, we need to promote a culture that encourages self-assessment and personal awareness. As we become aware of how our mindset changes under stressful conditions, we learn to automatically activate a recovery trigger that switches us toward safer backup options. When we recognize that we are using more force, feeling more stressed, and sensing rising workload, we recognize that we need to automatically switch safer backup plan. Pursuing the Master Class path guides pilots to recognize their early indications of bias, rationalization, and compromise. Armed with this awareness, they build personal firewalls to interdict failing trajectories. Through continuous debrief and introspection, we learn to skillfully identify our position on the event spectrum and apply the appropriate level of force, modification, abandonment, or innovation. The key parameter is appropriateness – accurately identifying what our situation requires and applying the appropriate blend of strategies to resolve the problem.
