Managing Threats and Errors

during Approach and Landing

How to avoid a runway overrun

This presentation provides an overview of the prevention strategies and personal lines-of-defense related to runway overruns. It is intended to enhance the reader's
awareness but it shall not supersede the applicable regulations or airline's operational documentation; should any deviation appear between this presentation and the
airlines AFM / (M)MEL / FCOM / QRH / FCTM, the latter shall prevail at all times.
 Landing Overruns
This presentation is primarily for self-study and reviews the threats and
errors that could lead to a landing overrun. It provides guidance of how to
manage threats and errors, thus how to avoid an overrun accident.

A threat is usually a physical aspect that may affect the safety of an operation;
an error is normally a consequence of human involvement either in the presence
of threats or without any hazard present at all.

A wet runway is a threat to a

landing operation more
landing distance required.

The failure of the crew to

understand the need for more
landing distance or to adjust
the level of braking would be
an error related to the threat.

Experience is what you learn

just after you needed it.

Speakers notes provide additional information, they can be selected by clicking the right mouse button, select Screen, select Speakers notes.

This presentation can be printed in the notes format to provide a personal reference document.
 Managing Threats and Errors during Approach and Landing

Section 1 - Threats
A threat or hazard is any situation, event, or circumstance that may affect
the safety of flight:

The effects of threats occur in the future so plan ahead

Threats are not errors, but they increase the potential for error

Threat
The process of managing threats involves:
Identify
Identifying and classifying a threat

Avoid
Avoiding the threat or threat situations

Trap
Trapping the threat and resolving or
mitigating any effects or consequences
Safe Flight
 Landing Threats
Analysis of worldwide landing incidents showed that a landing overrun is
more likely if:-

The approach was fast and landing attempted in excess of Vref +15kts

The approach was high, exceeding the recommended threshold

crossing height

The aircraft floated or is held off the runway for a smooth touchdown

The touchdown point is long, often beyond the normal landing area

The runway surface is wet or contaminated

There is a tailwind

Threat
These threats may result in an accident;
Identify
they can be managed:
Avoid Detected
Trap
Avoided
Trapped
Safe Flight
 Landing overrun
A landing overrun occurs when the aircraft landing distance exceeds the
distance available. The distance required to land and stop an aircraft is
effected by many factors in each of four phases; any single factor or
combination can create a threat that may result in an overrun.

1. Approach The manufacturers landing distance is based on crossing the

threshold at 50 ft, at the landing reference speed, Vref.
2. Flare
The runway is dry, with known friction coefficient.
3. Control Maximum braking is applied after touchdown.

4. Stopping Certificated landing distances have additional safety factors to

account for operational variability and runway conditions.

Threshold
height

Approac Flare Control Stop

h
 First Plan Ahead
Carefully review the expected landing performance during the approach
briefing. The pre-planned data uses forecasts and predictions made at
the time of dispatch. Recheck these and consider:-
Choice of runway available length, surface condition, dry / wet / contaminated *
Similar runway surfaces may not have the same level of friction
Wind - a downwind landing can significantly increase landing distance. Factors of
150% are applied to the landing distance
Maximum landing weight allowed - note the considerable differences in allowable
landing weight between into-wind and downwind landings
Check how close (%) the actual landing weight is to the allowed landing weight;
adjust the planned braking level accordingly
Consider any effects of non normal operations (MEL)
Carefully recheck the pre-planned performance when landing at alternate or
diversion airports

* Attempts to land on contaminated runways involve considerable risk and should be avoided whenever
possible.
 Approach threats
The most significant threats during the approach are:
Fast approach airspeeds - in excess of the planned value
High groundspeeds not appreciating wind effects
High and / or steep approach above the desired flight path
High energy is the combination of these conditions; early control of energy can
reduce these threats:

Plan and brief the approach; use approach gates that define the distance or
height where the correct airspeed and height (energy) must be achieved

Consider the effect of any speed correction for:- Gusting wind, Windshear,
and Icing conditions, recheck the landing distance required, adjust the
planned braking level according to the ground speed
 Approach management
A stabilised approach provides a basis for a good landing, it provides the
crew with the optimum conditions to flare, land, and stop the aircraft

An approach must be stabilised by 1,000 ft in IMC and by 500 ft in VMC

1. The aircraft must be on the correct flight path
2. Only small changes in heading and pitch are required to maintain the
correct flight path
3. The aircraft speed is < Vref+20 kts, < Vref + 15 kts at the threshold
4. The aircraft is in the landing configuration
5. Sink rate < 1,000 feet per minute
6. Power setting appropriate for configuration
7. All briefings and checklists have been performed
8. Instrument landing system (ILS) approaches - must be flown within
the equivalent of one dot of the glideslope or localizer
9. Visual approaches - wings must be level on final before 500 ft
10. Circling approaches - wings must be level on final before 300 ft

Flight Safety Foundation ALAR Tool Kit

 Landing Flare
A fast approach and / or excess height at the threshold are significant
threats to a safe landing:
The speed element of energy is the most important threat
2
Energy ~ Mass x Speed ( Energy is proportional to Mass x Speed x Speed )

An extended flare leads to a long deep touchdown, lengthening the landing and
roll out distances
De crabbing the aircraft in a crosswind uses up landing distance

Accurate speed and flight path control provides the optimum conditions for a
flare. Aim to touchdown within the relevant fixed distance markers.

Aircraft decelerate quicker on the ground than in the air.

 Flare management
Correct airspeed gives consistent aircraft feel for all landings
Aim for the ideal touchdown point on every landing
Aim for a safe landing; not always a soft landing
Downhill slopes may give a long touchdown

Threshold: less than Vref + 15, Height 50 ft

Next - touchdown point and speed (7 kt loss)

Touchdown within the relevant fixed

distance makers

Amber threats - avoid

For every 10 ft excess height
at the threshold, an additional
200 ft of runway is required.
 Control on the runway
As soon as the aircraft is safely on the runway, commence the
deceleration; brakes, spoiler, thrust reverse. Effective landing distance
available may reduced due to:-
Delayed nose-wheel lowering
Late application of brakes or reverse
Failed or late application of lift dump / spoilers

The control phase of a landing

is often overlooked, but when
the aircraft is at its highest
ground speed, any delay in
deceleration uses significant Respect wet runway
landing distance crosswind limits

100 kts uses 169 ft of

runway every second
 Manage deceleration threats
Do not delay lowering the nosewheel. Braking depends on ground
reaction, this requires all wheels on the runway.
Automatic spoiler / brake may depend on weight switches
Make a firm touchdown especially on a wet or contaminated runway

Be prepared for aquaplaning with ground speeds above

9x tyre pressure
Anticipate increased rudder input to control any crosswind effects
Check spoiler / thrust reverse deployment

Amber threats - avoid

For every 1 kt excess speed
above Vref, an additional 2% of
runway is required.
 Stopping the aircraft
The main threats to stopping the aircraft is the lack of braking
effectiveness; this depends on:-
Level of braking
Plan and use of the required level of braking for the conditions
Commence braking at high speed, dissipate energy early
Use full braking when required; safety before comfort

Runway friction
Wet runways have much lower friction levels than a dry runway
The friction depends on the runway surface, materials, and condition
Contamination (water, slush, snow, or ice) reduces friction to very low levels

Level of braking
Brake for safety not
for comfort

Do not leave braking until the end

 Manage all threats - every landing

Threats: Management:
Fast; above Vref+15 Plan - self briefing, crew briefing
High at the threshold Stabilised approach - through the gates
Wet Runway Adjust braking levels - wet runways, tailwind
Long landing

A good landing
Captain
 Managing Threats and Errors during Approach and Landing

Section 2 - Errors
Errors:-
are usually the result of past activities, they are consequences of an
action or inaction
reduce the margin of safety and increase the probability of accidents
or incidents

Errors in situation awareness - not

understanding the situation, which leads
to a wrong decision; due to poor
knowledge, time management, or lack
of attention
Decision errors - choosing the wrong
course of action; due to failures of
discipline, memory, or training, or by
violating rules and procedures, or giving
in to peer pressure
 Error Management
It is human nature to make errors, thus error management is a vital
safety device; the process is similar to threat management:
1. Identify situations that could lead to errors
2. Avoid these situations and circumstances that promote errors
3. Identify an error, trap the error, take corrective action, and check effectiveness

ERROR

Identify Most flying activities follow this process, many of the

actions are subconscious

We learn from errors, from our own and from other

Avoid people

Error management requires conscious thought to

provide awareness and understanding. Rules enable
Trap
us to avoid hazards; procedures trap residual errors

Safe Flight
 Not understanding the situation
Pilots may fail to recognise an uncommon or deteriorating
situation; there are many reasons for this:
The visual scene is ambiguous illusions, poor weather, not scanning instruments

Unaware of runway conditions landing risks mis-assessed or underestimated

Warning signs ignored - complacency, bad habit, lack of knowledge

Lack of time time available underestimated, rushed decision, presson-itis

No pilot intentionally chooses failure

What we think the situation is:

Common Uncommon
Uncommon

Failure to recognise the situation Recognise an uncommon situation

The actual situation:

Hazardous Error Success

Land when you should not Go Around when you should

Recognise a common situation Conservative error

Common

Success Failure
Land when you should Go Around without need

Swauger The recognition trap

 Expecting a situation
No two landings are the same!
The smallest change in conditions may overcome the plan
Because one marginal landing was successful does not mean that the next
attempt will be
Avoid complacency, you may not be able to land and stop:
Yes an accident can happen to you
Do not tolerate SOP deviation:
Avoid short cuts or thinking that you know better
Resist peer pressure:
It is OK to Go Around
ERRO
R

Identify First be aware of your errors, then other peoples errors

Monitor the environment, the aircraft and crew for

Avoid
changes or errors in the plan
Tra
p Avoid hazardous error provoking situations

Safe Flight
 Situation Awareness
Avoiding situation assessment errors:
Situation cues provide a mental model of what is happening; cues have to be
sought out and understood
See to understand; deliberately scan the situation to gain information,
compare this with the expected or the normal parameters
Know what to see and when to see it; be aware of distractions, focus attention
on landing threats and opportunities for error

See to understand
Know what to see and
when to see it

Airspeed, Altitude
Runway length
Surface conditions
Wind, Wet

Do not judge the situation

on just one parameter
 Acquiring Situation Awareness
Important situation cues for landing are:
The aircrafts actual approach path and airspeed in comparison with the ideal
flight path and the target air speed
The runway conditions, friction, and the required level of braking
The landing distance available for the ambient conditions, the aircraft weight
and configuration
Tailwind
Maintain an accurate picture of the
situation, check and recheck:-

Stable approach

On speed & height

Runway conditions

Landing distance available

Approac Flare Control Stop

h
 Maintaining Situation Awareness
Planning and think ahead
Create the plan in the landing briefing;
Aircraft weight speed landing distance required
Surface conditions landing distance required plan
Wind landing distance required monitor
compare
Readjust the plan if conditions change
Change the course of action
Be aware that apparently familiar situations hide change

Compare with the SOP

Landing gates, stabilised approach, speed / ht over threshold
Anticipate the next part of the plan
Go Around if unstable, if missing a gate, or fast at the threshold
Beware of bad habits do not deviate from the plan or SOPs

Change the course of action if a rule is violated

Situation Awareness
Plan
Monitor
Compare
 Decisions a course of action
A course of action is the result of a decision. Errors occur due to failures of
discipline, biased memory, or a weakness in training
In routine or time critical events, actions may become automatic; avoid bad habits
- landing fast or long, be aware of tailwind, wet runway, low braking levels
Most flight activity uses a mixture of assessment and action; these are the basis of
standard operating procedures (SOPs) follow all SOPs
Complex or unusual situations requires more thought; it is essential to have good
situation awareness and knowledge, and make time to think

Continuing an approach after

missing a stabilized approach
criteria is not the correct ERROR
course of action.
Identify

Avoid

Trap

Safe Flight
 Know the Risks
Risk = Threat or Error x Vulnerability x Consequence
Landing risks may be mis-assessed which may bias judgment:
Low awareness of personal vulnerability to error making

Not considering the consequences

Landing risks are bounded by knowledge:

High energy approaches are high risk manoeuvres
Respect boundaries of speed and height
Approach Gates
Respect cross wind and tailwind limits
Company SOPs

Wet runways require more landing distance

Adjust braking levels to suit surface conditions
Consequences?
Personal SOPs
Do not copy or repeat bad habits
Personal risk management
 Consider the Consequences
Possible fatalities or severe injuries
Probable collateral damage
Probable aircraft hull loss
Certain disruption, delay
Consequential cost
Dented pride

Most overruns are accidents; fatalities, injury, damage

Think about, and lower the risk factors before you have an accident
 More knowledge - lower risk, better decisions
Relative Landing Distances:
Be aware of additive values:-
Manufactures minimum distance:
Fast + 20%
Vref , 50 ft, dry, max brake. Certification
safety factor Tailwind + 20%
Long flare + 30%
High + 30%
+ 10kt fast
Wet + 40 %
+ 10kt tail

Long flare or + 100ft at threshold

Max brake stop requires 115% of minimum

dry distance, a reduced safety margin.
A fast landing also reduces the safety
Wet runway margin, and in a tailwind, there may be none!

Wet + Fast + Tailwind

Wet + High + Long

Ice / slippery runway

 More knowledge - lower risk, better decisions
Friction coefficient of runway surfaces:
Type of surface, condition of surface (rubber deposits) , dry, wet, contaminated

Runway
Friction Mu Certification terminology Crew / ATC report
1
DRY _ _ _ _ _ _ _ _ _ ICAO code
0.8
DAMP _ _ _ _ _ _ _ _ _ Dry, smooth
0.6
WET _ _ _ _ _ _ _ _ _ _ _ _
Good 5
Wet, grooved Med - good 4
0.4 CONTAMINATED
Med - fair 3
Water Patches _ _ Poor 2
0.2
Wet, smooth Nil 1
Flooded _ _ _ _ Unreliable 9
0 KIAS
0 50 100
ICAO Codes are relative to the runway conditions, thus good is only good for a wet runway, which may already
have a reduced safety margin
Grey areas: There is no overall accepted certification / operational correlation between mu meters and airplanes

Water, Slush, Wet Snow, Dry Snow, Compacted Snow, Ice

 Make the decision, your decision
Decisions depend on:
Understanding the situation take a wider view of the situation
Knowledge and risk assessment compare the situation with SOPs
Identifying safe courses of action dont focus on just one option

Choose the safest option, and then take action to correct any error

Dont depend on previous aircraft landing reports;

braking effectiveness varies with aircraft type,
equipment availability, and use of brakes

Dont have an accident by helping someone else,

it is OK to say No to ATC
unable to comply

Your Decision
Scan for situation cues
Use knowledge wisely
Assess risks
Consider consequences
Take action, do what is right
 Decision, a problem of choice
Deciding involves a choice, the choice of the safest option; choice
involves recall of memory and comparison of facts:
Memory can be biased to fit the apparent facts crosscheck and monitor the
situation, especially in a rapidly changing situation
False memories may be recalled from previous bad habit operations or
inappropriate procedures from other aircraft types refer to current SOPs
Previous low consequence decisions can develop into high consequence
situations that require revised decisions continually reassess earlier decisions
Complex situations may indicate a failing course of action reassess,
crosscheck, and intervene if an error is detected

Make time
Reduce speed early; 180 kts is approx 3 nm/min (900ft/min),
whereas 120 kts is 2 nm/min (600 ft/min)
 Summary
Avoiding a landing overrun
Identify, avoid, and trap threats and errors.
Maintain good situation awareness: airspeed, runway friction
Have a plan, give a briefing: compare the situation with the plan
Knowledge of no-go areas: flooded & contaminated runways
Speed above Vref+15, long landings, strong tailwinds
Follow SOPs: use approach gates, speed / height
Do not tolerate violations, beware of bad habits
Resist peer pressure
Brake for safety not for comfort

Manage the consequences of error

Revise the plan - it is OK to go around
Make time
Have a safe landing before an on time landing
 Every
Every landing
landing
A
A Safe
Safe Landing
Landing

A good landing
How heavy is the aircraft Captain
How long is the runway is a good example for everyone
How fast is the aircraft
How wet is the runway
Head / Tailwind
On Speed
Respect the stabilized approach criteria
Height over the threshold
How much braking to use