How “Get Home-itis” Can Negatively Influence Our Decision-Making

IASAP 18487 (C-17) WEATHER MINIMUMS LED TO UNSTABLE APPROACH DURING RNAV (AREA NAVIGATION) NON-PRECISION APPROACH

Preamble: Before we dive into the Aviation Safety Action Program (ASAP) analysis, the Ops RAMS (Operations Risk Assessment and Management System) Branch lauds the submitter for a powerful, self-critiquing assessment of their performance. In a Just Culture environment, we sincerely appreciate crew members who share their errors so that we can all learn how to improve our performance. Additionally, the crew member showed true professionalism and candor in assessing their decision-making. Thank you for contributing to Proactive Safety!

Have you ever had one of those moments in your flying career when you are on the final leg of a long trip back to home station and cannot wait to get home? You cannot wait to see your family, or you have leave planned for the following day—you cannot get done with the trip fast enough! Unfortunately, the weather is down to minimums, you are short on crew duty day, and your crew is tired. You just have to “sneak†below the weather, stick the landing, and you are home-free!

The overwhelming desire to “get home†can adversely influence our judgment and decision-making. Recently, one crew member shared their experience and lessons learned in an ASAP in which “Get Home-itis†negatively impacted their decision-making.

ASAP 18487 SUMMARY

After air-refueling on a night local training sortie, weather had deteriorated at home station to just above minimums. With the ILS [Instrument Landing System] approach inop, we were forced to conduct an RNAV Area Navigation non-precision approach. After we began the approach, there was a broken layer now reported 300’ variable 700’. We continued the approach and eventually established level flight at the LNAV MDA [Lateral Navigation Minimum Descent Altitude]. The runway was obscured in the clouds until about a mile away when the clouds broke, and [we] had visual contact with the runway. I made a split decision [to] continue to land, which resulted in an unstable approach. We received the GPWS [Ground Proximity Warning System] “Sink Rate†aural warning shortly before touch down but landed softly about 2500’ down the runway. We were also close to minimum fuel before we needed to depart to our alternate and would have had to spend the night and possibly not make it back to home station until the following evening due to the weather. This [possibility] had a negative effect on my decision-making.

SUBMITTER’S RECOMMENDED ACTION

Regardless from the fact that the C-17 is not yet certified for constant glide path non-precision approaches, we still need to operate with sound judgment and decision-making with what we have. I let other factors weigh into my decision-making which resulted in an unstable approach. The best thing to go [do] simply execute a Go-Around and worry
about diverting after the approach.

This narrative is a very constructive ASAP with some excellent lessons learned from a Threat and Error Management perspective. The following analyzes some factors that the submitter highlights:

Threat #1: Instrument meteorological conditions (IMC) / fog / low visibility: The submitter indicates that weather was a factor in this event, with a broken layer reported at 300 feet variable 700 feet. More specifically, the submitter reported 1,000 feet of overcast clouds with a broken cloud layer, variable 300 feet to 700 feet (after they started the approach), 9° C, and rain. Due to our training and emphasis on Instrument Flight Rules procedures, we can sometimes become complacent about the weather as a threat. As we conduct our pre-mission planning, we might review the terminal aerodrome forecast and meteorological aerodrome reports and evaluate alternates and fuel planning but overlook the true impact of the weather on the mission profile. In other words, we go through the motions of reviewing the weather but fail to bring weather to the forefront of our thinking and preparation for the mission. In this particular ASAP, we can see how the weather increased the operational complexity of the approach and landing, thus becoming a factor in the event.

Threat #2: Unusable or improperly functioning Navigational Aids: The ASAP also highlights that the ILS was out of service, which forced the crew to conduct an RNAV (Area Navigation) (GPS) non-precision approach. Wow, talk about a synergetic effect! Not only was the weather marginal, but the most precise approach was no longer an option. As we evaluate the threats mentioned in the ASAP, we can now appreciate how a “routine†night training mission can quickly become challenging due to weather and limited instrument approach options.

Threat Outcome: Linked to crew error. As we will discuss in a moment, these threats were contributing factors to the errors that the crew committed. Most likely, the IMC conditions were more of a factor as the submitter indicates the runway environment was not visible until approximately 1 mile from the runway.

Error #1: Unstable Approach (Descent rate?): The submitter is very broad in describing the errors committed but indicates the outcome was an unstable approach. We cannot tell from the narrative if the approach was unstable for airspeed, bank angle, or descent rate; however, the submitter does indicate that the GPWS “sink rate†alert sounded shortly before touchdown. Given the facts by the submitter of being level at the LNAV MDA, the runway environment not being in sight until approximately 1 mile from the approach end, and the GPWS “sink rate,†most likely the unstable approach was the result of a high descent rate.

Error #2: Unstable Approach (Go-Around Call?): As previously mentioned, the submitter only describes the event as an unstable approach. While we might see this unstable approach as one error, there is most likely a second error in this event. Consider the Stabilized Approach Procedures as defined in the Air Mobility Command (AMC) supplement to Air Force Manual 11-202, Vol 3, Flight Operations:

• 29.8.2.3.3. (AMC): “If unstable or not in final flap configuration at 500 feet HAT [height above touchdown], the PM [Pilot Monitoring] will call “Go around,†and the PF Pilot Flying] will execute a go-around.â€
• 29.8.2.4. (AMC) From 500 feet HAT to the runway. “From 500 feet HAT to the runway, if the criteria in paragraph 29.8.1 are exceeded, the PM or any other crew member will announce “Go around,†and the PF will execute a go-around.â€

Given the fact that the submitter states that a landing was made from an unstable approach, a go-around call was not made, or a go-around call was ignored. In either case, the procedural barrier, which is outlined in the procedures to prevent a landing from an unstable approach, was breached.

Error Outcome: Undesired State: The submitter reveals that the ultimate outcome of this sequence of events was an unstable approach, which is an undesired state. Additionally, the undesired state is further amplified by the aircraft GPWS “Sink Rate†warning. These aircraft safety systems, such as GPWS, the Ground Collision Avoidance System, and the Terrain Avoidance and Warning System, are additional critical safety barriers to warn the crew and prevent Controlled Flight Into Terrain (CFIT). In this case, the GPWS warned the crew of the high descent rate within close proximity to the ground, thus emphasizing the undesired state.

Crew Resource Management (CRM, Negative Contributing Personal Factor): “Get Home-itis:†Sometimes, our decision-making and judgment are erroneously influenced by personal factors and attitudes. As highlighted by the submitter, their decision-making was clouded by a “Get Home-itis†attitude—that overwhelming personal need to make it home, which impaired their judgment. The submitter provides a very honest assessment of how their personal desire to get home that night negatively influenced their decision-making: “We were also close to minimum fuel before we needed to depart to our alternate and would have had to spend the night and possibly not make it back to [the] home station until the following evening due to the weather. This [possibility] had a negative effect on my decision-making…Regardless [of] the fact that the C-17 is not yet certified for constant glide path non-precision approaches, we still need to operate with sound judgment and decision-making with what we have. I let other factors weigh into my decision-making which resulted in an unstable approach. The best thing to go [do] is simply execute a Go-Around and worry about diverting after the approach.†That statement is a very powerful lesson learned—well said!

Wrapping it up: As indicated by the submitter, the focus of this ASAP is the decision-making. Their decision-making was clouded by a “Get Home-itis†attitude, which impaired their judgment. The situation was further complicated by the deteriorating weather, limited instrument approach options, and minimum fuel state, which led to a snap decision rather than a sound, deliberate thought process.

Overriding our personal attitudes is sometimes the most difficult CRM issue to combat. The best defense is to anticipate these events in our pre-mission planning. Try to anticipate the threats, such as poor weather and limited instrument approach options, and, if possible, mitigate them before you step to the jet. Next, monitor your plan and its critical factors, plan to terminate early, or have a backup plan so you do not “paint yourself into the corner,†thus eliminating the possibility of a snap decision. Next, inform your crew if you need to make it home, so there is no hidden agenda. Tell your crew in advance if you have leave scheduled for the next day or an important event to attend, so they can help you avoid an unnecessary risk of pushing a bad decision. Do not let yourself or any other crew member accept an unnecessary risk during a training mission.

Using Threat and Error Management, we can see how even a training mission can quickly degrade into a challenging ordeal. Thanks to the submitter’s voluntary participation in this proactive safety program, we can learn from this event. I would much rather read a meaningful ASAP, such as this one, than read a safety report in which lives were lost.