Night Operations Into Queenstown International Airport: A Human Factors Analysis

Night Operations into
Queenstown International Airport

A Human Factors Analysis
Prepared for Jetstar Airways Ltd

By Captain Mark Peters
Night Operations into Queenstown International Airport 2
CONTENTS
Executive Summary……………………………………………………… 3
Abbreviations…………………………………………………………….. 5
1. Introduction………………………………………………………. 6
1.1 Background…………………………………………………… 6
1.2 Scope………………………………………………………….. 6
1.3 Areas of Research…………………………………………….. 7
2. Spatial Disorientation……………………………………………. 8
2.1 Visual Illusions……………………………………………….. 8
2.1.1 Black Hole Effect……………………………………… 8
2.1.2 Aerodrome Lighting Failure on Approach…………….. 10
2.2 Vestibular Illusions……………………………………………. 11
2.2.1 Somatogravic and Somatogyral Illusion………………… 11
2.3 Contributing Factors…………………………………………... 12
2.3.1 Pilot Factors……………………………………………. 12
2.3.2 Aircraft Factors………………………………………… 13
2.3.3 Operational Factors…………………………………….. 13
2.3.4 Environmental Factors…………………………………. 14
2.4 Preventative Measures………………………………………… 15
3. Effective Flight Path Monitoring………………………………… 16

3.1 Human Factors Limitations…………………………………….17
3.2 Recommendations to Improve Flight Path Monitoring……….. 18
3.2.1 Areas of Vulnerability…………………………………..18
3.2.2 Flight Path Monitoring ‘Sampling Rate’………………. 19
3.2.3 Task/Workload Management in an AOV……………… 20
4. Threat and Error Management………………………………….. 21

4.1 Introduction to TEM Models………………………………….. 21
4.2 A Systemic Approach to Mitigating Strategies……………….. 21
4.3 TEM and Jetstar……………………………………………….. 22
4.4 Incapacitation………………………………………………….. 23
4.5 Unstable Approaches and Runway Excursions…….…………. 24
4.6 Procedural Drift……………………………………………….. 27
5. Startle Effect………………………………………………………. 29
5.1 The Startle/Surprise Reaction…………………………………. 30
6. Conclusion………………………………………………………… 32
7. Recommendations………………………………………………… 35
References
Appendix
Executive Summary
Jetstar Airways currently operates flights into Queenstown International Airport, a

popular tourist destination located in the West Otago region of New Zealand’s South
Island. The airport, located near a large lake and surrounded by high mountainous
terrain, is currently only utilised during daylight hours using specialised approach
procedures that are approved by the Civil Aviation Safety Authority. Jetstar Airways
wishes to expand flying operations to include night hours, which would remove
current daylight restrictions on arrival and departure times and enable flexibility in
flight scheduling during darker months of the year.
Night operations are considered more hazardous than daylight flying, the lack of
visual stimuli is known to cause disorientation, errors are more prevalent and fatigue
becomes more of a factor. This report was commissioned to examine key areas of
concern with regard to night operations into Queenstown from a human factors
perspective and provide recommendations to advance operational safety.
The report outlined four main areas of inquiry: Spatial Disorientation, Effective Flight
Path Monitoring, Threat and Error Management and Startle Effect. It was discovered
that Spatial Disorientation (SD) is most prevalent at night due to the loss of visual
stimuli and increased chance of visual and vestibular illusions. Due to the geography
of the region combined with low light conditions, Queenstown presents conditions
conducive to promoting SD events. Pilots need to be made aware of the prevalence of
insidious phenomena such as ‘black hole effect’ and ‘samatogyral illusion’ along with
knowledge of factors that may contribute to SD.
Effective Flight Path Monitoring (EFPM) addressed issues of flight crew error during
the approach and departure phase of flight. The Human Factors Aviation Industry
Round Table meeting in 2012 expressed concern at the high number of
accident/incident rates that were occurring due to ineffective flight path monitoring.
Research revealed that there is a conflict between the vigilance and concurrent task
workload management required for effective flight path monitoring, and the human
factors limitations that affect a pilot’s ability to sustain this process effectively.
Recommendations in this area include those suggested by the Flight Safety
Foundation where areas of vulnerability are identified and specific monitoring rates
and task/workload management techniques are applied.
Threat and Error Management continues to provide a framework that assists in

understanding, the inter-relationships between safety and human performance in
dynamic and challenging operational contexts. The report found that encouraging
positive CRM behaviours is vital for identifying threats, both expected and
unexpected, and providing successful outcomes. Pilots are provided relevant
information with regard to TEM models and LOSA audit findings, however it was
recommended that greater emphasis be placed on delivering mitigating strategies and
proven techniques to overcome normal human limitations that may erode safety
margins, and addressing the high numbers of pre-departure interruptions to flight
crew.
Pilot incapacitation remains a significant threat to safety, although statistics show a

low probability of occurrence, simulator research showed alarming evidence with
regard to detection time and unsafe outcomes. Jetstar training and associated
procedures with regard to pilot incapacitation are considered robust. Adherence to
SOP and challenging unusual flight regimes will ensure early detection and allow for
effective management. A consideration for inclusion in incapacitation training is the
resulting increased workload and possible task saturation the remaining crewmember
will experience that may impair decision-making with regard to continuing or
diverting the flight.
Runway safety events dominate current global safety statistics, namely runway
excursions and overruns, with high rates of occurrences involving commercial jet
aircraft. Evidence shows that a large contributing factor to these events is the crew’s
decision to continue an approach to land when the aircraft is outside of normal
stabilised approach criteria. An appropriate culture that includes a ‘no fault’ go
around policy as well as educating crew as to the dangers of continuing unstable
approaches is deemed essential, and Jetstar maintain such a culture.
Procedural drift is where work being done on the front line differs to that which is
stipulated by the company rules. It occurs when overly cautious rules are perceived to
impede on objectives, alternative methods are then created and soon become the norm
(safety shortcuts). These insidious latent threats occur when the flow of information
from front line staff is inadequate or when company rule makers fail to engage with
end users. Jetstar employs a ‘workaround feedback’ form that enables crew to advise
managers what deviations are occurring and why. This procedure enables flight
operations departments to judge the effectiveness of current policy and intervene
where appropriate.
Recent aviation accidents have highlighted the need to examine how pilots react when
faced with unexpected critical failures. Research shows that advances in technology,
that has led to the inherent safety and reliability of aircraft, has created an unfortunate
conditioning of ‘normalcy’ amongst pilots. This universal acceptance of reliability
may contribute to underperformance during surprise events by inducing a
‘startle/surprise response’ that impairs normal cognitive processes and reasonable
thought. Research in this area is relatively new and it is recognised that recreating
‘startle effect’ in a training environment will be difficult due to pilots preparing for
simulator training scenarios. It is considered beneficial however to introduce the
concept of ‘startle effect’ to pilots to heighten awareness of the phenomena, how it
occurs and what affect it may have on handling unexpected events.
Abbreviations
AAE Above Aerodrome Elevation HUD Head Up Display
ALAR Approach and Landing IATA International Air Transport
Accident Reduction Association
AOV Area of Vulnerability ICAO International Civil Aviation
ASAP Aviation Safety Action Organization
Program IFR Instrument Flight Rules
ASRS Aviation Safety Reporting IMC Instrument Meteorological
System Conditions
ATC Air Traffic Control JQ Jetstar
ATSB Australian Transport Safety JRRQ Jetstar Risk Register
Bureau Queenstown
BASI Bureau of Air Safety LOSA Line Oriented Safety Audit
Investigation PAPI Precision Approach Path
BEA Bureau d’Enquetes et Indicator
d’Analyses (Office of PFD Primary Flight Display
Investigations and Analysis) NASA National Aeronautics and
CASA Civil Aviation Safety Authority Space Administration
CFIT Controlled Flight Into Terrain ND Navigation Display
CRM Crew Resource Management NTSB National Transportation Safety
DAME Designated Aviation Medical Board
Examiner NVG Night Vision Goggles
EFPM Effective Flight Path NZQN Queenstown (ICAO)
Monitoring OSCAR Operational Safety and
EGPWS Enhanced Ground Proximity Company Advisory Report
Warning System PF Pilot Flying
FAA Federal Aviation PM Pilot Monitoring
Administration RNAV Area Navigation
FCOM Flight Crew Operating Manual RNP Required Navigation
FCTM Flight Crew Training Manual Performance
FDM Flight Data Monitoring RS Runway Safety
FMA Flight Mode Annunciator SA Situational Awareness
FOQA Flight Operational Quality SD Spatial Disorientation
Assurance SOP Standard Operating Procedure
FSF Flight Safety Foundation TEM Threat and Error Management
HF Human Factors UAS Undesired Aircraft State
HFACS Human Factors Analysis and WG FSF Working Group
Classification System ZQN Queenstown (IAT
1. Introduction
1.1 Background
Queenstown airport is located in Frankton, Otago approximately eight kilometres
from the township of Queenstown. The aerodrome consists of two active runways
situated 1171ft above sea level and is surrounded by high mountainous terrain. The
main runway is 1777 meters long and is intersected by a shorter runway of 720
meters. Jetstar Airways currently conducts daytime operations into Queenstown,
alongside other airlines, utilising the latest techniques in performance-based
navigation. Current approach design enables crew to operate Jetstar A320 aircraft to a
minimum height of 400ft above aerodrome elevation where a decision is made to
either continue the approach and landing, or abort the approach where a ‘go-around
procedure’ is performed. The aircraft automation system is utilised to its maximum
capability and pilots are only required to manually fly the aircraft in the event of an
auto flight malfunction, specific aircraft and navigation system errors, or when the
pilot takes over to perform the landing manoeuvre.
Whilst Jetstar has successfully operated into Queenstown during daylight, it wishes to
expand flying operations to include night hours. The risk assessment associated with
the foundation safety case for night operations has identified a number of hazards, for
flying in darkness, that require additional mitigating strategies. This report was
commissioned to examine the implications of night operations at Queenstown airport
from a human factors perspective and to provide recommendations that may advance
operational safety.
1.2 Scope
Night operations at Queenstown airport do not stand to affect the operation of the
aircraft insofar as the aircraft performance is not determined by the amount of light
present. Physical performance of the aircraft, as determined by weight, altitude and
temperature, may vary during night hours (due to diurnal variations and localized
weather phenomena) however this is covered adequately by current Airbus and Jetstar
operations manuals and are outside the scope of this report. Jetstar recognises the
limitations on human performance during night hours with reduced visual stimuli
combined with inclement weather conditions, or other phenomena, in an environment
that demands acute situational awareness, precise flying ability and sound decision
making skills. The Flight Safety Foundation (FSF) suggests that human error is
involved in more than 70 percent of aviation accidents (FSF, 2009) the Foundation’s
Approach and Landing Accident Reduction (ALAR) toolkit also shows alarming
statistical correlations between aviation accidents and flight during darkness and/or
poor visibility (ALAR, 2009).
This report addresses key areas of concern identified by leading aviation safety
authorities and their relationship to night operations at Queenstown airport. The report
will also address hazards generated by the Jetstar ‘Risk Register for Queenstown
Airport Night Operations’ (JRRQ). The report is divided into four main areas of
concern: Spatial Disorientation, Effective Flight Path Monitoring, Threat and Error
Management and Startle Effect.
1.3 Areas of Research

Section two looks at ‘Spatial Disorientation’, which is the risk associated with night
flying that is of a physiological nature. The human body, and its systems that help
maintain spatial awareness, has evolved for use on the ground and not for flight. The
effects of visual and vestibular illusions may be so overpowering as to cause flight
crew to challenge what their instruments are telling them or lose sight of where they
are completely. This section investigates some of the more common phenomena, why
they occur, and what can be done to mitigate their effects and/or recognise when it is
occurring. Some preventative measures are introduced and recommendations for
training and education.
Section three looks at ‘Effective Flight Path Monitoring’. Given the precise
navigational requirements and high level of vigilance required by pilots performing
RNP approaches and departures at Queenstown, this is an important area of human
performance research. Leading flight safety organisations have expressed concern at
the level of events occurring that have involved ineffective monitoring as a factor.
This section looks at the human limitations of flight path management and provides
recommendations to improve monitoring techniques and task/workload management
in areas where crew are most vulnerable to committing errors.
Section four discusses ‘Threat and Error Management’ reviewing the models
developed by the LOSA collaborative and the various categories of threats, errors and
undesired aircraft states. A systemic approach to threat and error mitigation is
discussed with CRM techniques identified as the best defence for any threats
encountered whether expected, or unexpected. Jetstar LOSA data shows that the
company could improve in areas in which they have influence over distractions and
interruptions to crew during the critical pre-departure stage of flight.
Specific threats identified in section three include ‘incapacitation’ where the

importance of detection through strict adherence to SOP and normal flight regimes is
highlighted as well as drawing attention to issue of task/workload saturation of the
remaining crewmember. The link between continued unstable approaches and runway
safety events, including the behavioural traits and operational pressures identified as
contributing to this type of decision error. Finally, threats pertaining to ‘procedural
drift’, the intentional non-compliance of policy and procedure due to a perceived
incompatibility between safety procedures put in place by subject matter experts and
the actual procedures required to execute the task.
Finally, section five introduces the topic of ‘Startle Effect’, a relatively new area of
inquiry for aviation human factors. This section explains how increased aircraft
reliability has caused an unwanted side effect of expected ‘normalcy’ where pilots
have been conditioned to expect things to function ‘without error’ and are taken by
surprise when they do not. This insidious effect has contributed to pilots
underperforming during surprise critical events and has been attributed to many recent
aircraft accidents. The research describes an innate human reflex to respond
impulsively when faced with unexpected events that are perceived as life threatening.
Training techniques that may aid in pilots handling unexpected critical events are
discussed along with information to raise pilot awareness of these phenomena.
2. Spatial Disorientation
Statistical data and anecdotal information shows that the level of risk for flight
operations that rely only upon external visual cues for guidance – such as the visual
segment of flight under instrument flight rules (IFR) – is greater at night than during
the day. In all phases of flight and during operations on the ground, specific kinds of
aircraft accidents occur more frequently and with greater severity during visual flight
operations during darkness (Wilson, 1999). Night operations are considered more
hazardous than daylight flying, this is because the horizon is not often visible, optical
illusions are more prevalent and fatigue is often more of a factor. Jetstar has identified
areas of concern that include reduced spatial or situational awareness, black-hole
phenomena, false horizon, samatogravic effect and reduced depth perception. All of
these issues fall squarely into the category of ‘Spatial Disorientation’ (SD), which is a
very common problem and is well recognized as the cause of aviation accidents
(Newman, 2007).
Dr David G. Newman of Flight Medicines Systems Ltd produced a comprehensive

report for the ATSB in 2007 explaining the various types of SD in the aviation
environment and suggested strategies for managing the risk associated with SD
events. Due to the scope of this project only those visual and vestibular illusions most
likely to be encountered by Jetstar crew performing night operations at Queenstown
are considered. It is assumed that Jetstar pilots already have a broad understanding of
illusion phenomena from Jetstar ground training courses, however a refresher is
warranted to remind pilots of the hazards of night flying through areas of high terrain.
2.1 Visual Illusions

The FSF Approach and Landing Accident Reduction (ALAR) task force found that
disorientation or visual illusion was a causal factor in 21 percent of 76 approach and
landing accidents worldwide from 1984 to 1997 (Flight Safety Foundation, 2009).
Given that the visual system is the dominant system for normal operation, a visual
illusion can be very powerful (Newman, 2007). The following section describes an
insidious visual illusion, the ‘black hole effect’, which may occur during night
operations at Queenstown.
2.1.1 Black hole effect1

During the day, a pilot’s depth perception helps estimate the distance to an airport, as
well as the aircraft’s height above it. But in darkness, with the absence of visual cues,
such as shadows, topographical references or colour variations, the pilot has little or
no depth perception. Without depth perception, estimating distance and height
becomes more difficult (Schiff, 1994).
The ‘black hole effect’ is the term given to the visual illusions associated with
approaches to aerodromes located in areas surrounded by dark featureless terrain.
Reduced visual cues combined with physiological limitations of the human eye have
caused even very experienced crews to fall victim with catastrophic consequences.
Whilst a great deal of industry attention has been directed towards black hole effect,
accidents continue to occur as a result of the phenomena. It is important to note that
although Jetstar flight crew involved in night operations into Queenstown are

1
Risk register numbers 42, 43 & 55
experienced and suitably qualified, evidence shows that an awareness of black hole
effect is by no means a guarantee of immunity. Whilst pilots conducting approaches
confirm correct approach slope guidance using both land based and aircraft navigation
aids, it is important for crew to refresh their understanding of black hole effect to
mitigate any effects of SD it may cause.
Queenstown aerodrome is located on the northern shores of a Lake Wakatipu, the

approach paths to both runway vectors stretch across large areas of farmland, lakes
and rivers. The runway itself shares a border with a golf course, farmland, a shopping
area and the small town of Franklin all of which is surrounded by high mountainous
terrain. During night hours with poor moonlight and/or overcast skies the aerodrome
position in relation to local geography presents a risk due to black-hole effect.
Boeing engineers Conrad L. Kraft and Charles L. Elworth conducted extensive

research into the problem and confirmed that pilots conducting black hole approaches
tend not to vary their descent profiles due to runway perspective as they normally do
during conventional straight in approaches, instead they descend whilst unwittingly
maintaining a constant visual angle (Kraft & Elworth, 1969). The visual angle is the
area occupied by the destination airport (and surrounding lighting) in a pilot’s vertical
field of vision.
Figure 1 demonstrates the variations in visual angle relative to aircraft position, both
horizontally and vertically. As the aircraft moves forward at a constant altitude the
runway occupies a greater amount of visual angle, to the pilot the runway gets bigger
as the aircraft moves closer. Similarly, if the aircraft could descend vertically at a
fixed distance from the runway, the visual angle decreases therefore the runway looks
smaller. It would seem logical then that a constant visual angle could be maintained
as the aircraft moves closer to the runway whilst descending, however this is not the
case and in fact a constant visual angle on approach will lead to a dangerously low
approach and possible CFIT.
Figure 1. Changes in visual angle relative to aircraft position (Schiff, 1990, p. 3)
Figure 2. Constant visual angle versus normal approach path (Schiff, 1990, p. 3)
The result of maintaining a constant visual angle on approach is depicted in figure 2.

The problem is mathematical in that the pathway resulting from a constant visual
angle is actually an arc with a large radius cantered high above the light pattern the
pilot is referencing. Note that the pathway is well below the required three-degree
approach path required. Also of note is that the circumference of arc is sufficiently
large, meaning the flight crew may never detect they are flying on an arc away from
the required flight path. The black hole effect is an insidious hazard in that pilots
following what they perceive as a ‘safe and logical’ approach path will in fact result
in a slow and undetectable deviation towards terrain and obstacles.
Kraft and Elworth concluded that the problems associated with a black hole approach
appear to be aggravated by:
• A long straight-in approach to an airport located on the near side of a small
city
• A runway length-width combination that is unfamiliar to the pilot
• An airport that is situated at a slightly lower elevation and on a different slope
than the surrounding terrain
• Substandard runway and airport lighting
• A sprawling city with an irregular matrix of light spread over various hillsides
beyond the airport (Kraft & Elworth, 1969)
Jetstar crew operating into Queenstown at night will utilize various standard operating
procedures to mitigate the effects of black hole phenomena. These include:
• Use of runway Precision Approach Path Indicator (PAPI) lights;
• Lateral and Vertical guidance provided by the RNP approach coding;
• Auto flight systems;
• Approach path monitoring and stabilized approach criteria; and
• Enhanced Ground Proximity Warning System (EGPWS)
Jetstar pilots operate aircraft at night on a regular basis and are familiar with the
hazards it can present. Flying into Queenstown at night however will initially be
unfamiliar to crew and the effects of black hole phenomena will be unknown. It may
not present an issue to one crew whilst in another it may be so overpowering they
could conclude the PAPI and/or vertical guidance is inaccurate, creating confusion
and prompting an inappropriate response.
2.1.2 Aerodrome Lighting Failure On Approach2

One must also consider the event of full or partial lighting failure of the aerodrome
lighting system, including the PAPI, whilst on approach. In the case where failure of
various elements of the aerodrome lighting system are not detected or occur without
warning when the aircraft is at a critical stage of flight (e.g. on short final approach)
crew must be aware of the serious consequences this affect may have on SD with
regard to visual illusions and flight path containment.
Presently, Jetstar holds an approval (Instrument number: MATFO 183/06) to continue

operations to aerodromes without serviceable approach slope guidance for a period of
up to seven days. There are several caveats to this approval, these being that the
approach slope guidance must not be specified as an essential requirement, approval

2
Risk register number 55
must be sought from the General Manager Flying Operations and specific training and
weather requirements must be met. Due to the considerable reliance on approach
slope guidance and the prevalence of visual illusions in its absence, Jetstar considers
that all elements of the aerodrome lighting (except obstacle lighting) must be
operational to initiate and continue and approach to landing.
Clear procedures for discontinuing the approach in the event of detected aerodrome
lighting failures should be delivered to crew so there is no question as to the
seriousness of this failure with regard to visual illusions and SD.
2.2 Vestibular Illusions

The vestibular system consists of the balance organs in both inner ears and is
designed for motion detection during surface of the earth operations. In flight, their
inherent limitations make them susceptible to error creating an erroneous sensation of
movement that contributes to SD. When paired with visual illusions such as taking off
into a ‘black hole’ vestibular illusions can be very overpowering. As Queenstown
presents such an environment, the JQRR has identified the following hazards.
2.2.1 Somatogravic and Somatogyral Illusion3

Somatogravic and somatogyral illusions are the two most common forms of vestibular
or ‘false sensation’ illusions that result in SD. It is most commonly encountered when
no clear horizon is present and flying wholly or partially by visual reference. Both
somatogravic and somatogyral illusions are most likely to occur in conditions of
marginal external visual reference or in visual ‘dark night’ conditions (SKYbrary,
2014). A report from the then Bureau of Air Safety Investigation (BASI), now part of
the Australian Transport Safety Bureau (ATSB), examined dark night take-off
accidents in Australia between January 1979 and May 1993, and found that of the 35
accidents in this period, 15 of them (42 per cent) involved SD as a primary factor
(Newman, 2007).
The vestibular organs are part of the human body’s mechanism for achieving posture
and stability. Changes in linear, angular and vertical acceleration which occur as a
result of flight control inputs, made to accomplish a change in the flight path, are
detected by the vestibular system and may create either or both of these illusions.
Somatogravic illusion is where there a strong sensation of pitching up during aircraft

acceleration as would be experienced in a take off or go-around procedure. Assistant
Professor of flight technology at Washington University and FAA flight safety
counsellor Dale R. Wilson (1999) explains that the greatest hazard occurs just after
liftoff when the aircraft is in the climb phase of flight, especially if that climb is made
into a ‘black hole’. Linear acceleration is accurately detected by the vestibular system,
however in the absence of strong visual cues the brain assumes that the linear
acceleration is in fact a pitch up event. This ‘false climb’ illusion, may lead to a nose
down response by the pilot, causing the airplane to descend into the ground or water
(Benson, 1988). Pilots who rely solely on visual cues after a night takeoff may fail to
establish the required climb angle to clear unseen rising terrain ahead.

3
Risk register numbers 42, 43 & 55
Pilots departing from Queenstown during hours of darkness will experience a takeoff
into a ‘black-hole’ especially on runway 05 where the takeoff departure track is
initially towards featureless terrain with no lighting. Departure from runway 23 is
initially towards a portion of Queenstown hill where there is some housing and street
lighting on the edge of the lake boarding rising terrain to the west. Current takeoff
procedures in both normal and abnormal procedures (e.g. an engine failure on takeoff)
require pilots to monitor rotation rate and climb attitude, confirming a positive climb
rate before retracting the landing gear. In the event of human error due to
somatogravic illusion, in both the takeoff and go-around phases of flight, the EGPWS
(specifically Mode 3: Altitude Loss After Takeoff) would trigger an aural alert “Don’t
Sink, Don’t Sink” as well as a visual alert in the cockpit.
Somatogyral illusion, also known as the graveyard spin or spiral (Benson, 1988),
occurs when the pilot either deliberately or inadvertently enters a spiral turn or spin.
For obvious reasons Jetstar crew would never intentionally perform such a manoeuvre
however it is prudent for pilots to be aware of the effects when considering the human
factors of unusual attitude recovery. During entry to the turn the vestibular system
detects an initial angular acceleration, however when the turn is stabilized and angular
acceleration returns to zero, the system no longer signals a turn is occurring. Normally
the visual system takes over and the turn is detected by confirmation of visual cues
outside the aircraft, but in the absence of visual cues the pilot may experience a
sensation that they are no longer turning. When the spiral turn is halted (e.g. during
recognition and correction of an unusual attitude) and the aircraft is returned to
straight and level flight, the vestibular system may cause a strong sensation of a turn
in the opposite direction. This may lead to the pilot returning the aircraft into the
original spiral turn to cancel out the sensation of rotation (Newman, 2007).
2.3 Contributing Factors

There are several factors that contribute to an SD event. The FSF discuss spatial
disorientation broadly within the ALAR toolkit as a factor contributing to approach
and landing incidents and accidents. Newman categorizes contributing factors to SD
into four distinct yet overlapping groups: pilot, aircraft, operational, and
environmental factors. Recognition of these key factors can go a long way to
producing preventative measures prior to flight and minimizing the potential for an
SD event to occur during flight.
2.3.1 Pilot Factors

Newman’s report states that pilots should only fly when physically and mentally well.
Any illness that affects the vestibular system is likely to increase the risk of
disorientation during flight; anxiety and stress can lead to more perceptual errors
being made as well as affecting recognition and recovery from disorientation.
Prescription and over the counter medicine can impair the quality of information
going to the brain and how that information is processed increasing the chances of
disorientation. Medications that are capable of such effects include common cold
medications, allergy medications and some painkillers to name a few. Alcohol has
been shown to significantly affect the normal functioning of the visual system and is
globally recognized as a major contributor to motor vehicle accident statistics. Whilst
the acute effects of alcohol are well known, it is a lesser-known fact that the effect of
alcohol on both the visual and vestibular system can persist for up to several days
after blood alcohol levels have returned to zero (Gibbins, 1988; Model & Mountz,
1990; Newman 2004; Oosterveld, 1970; Ryback & Dowd, 1970).
2.3.2 Aircraft Factors

The report suggests that single pilot operations face the most serious challenges to
identifying and handling disorientation. Jetstar operate in a ‘multi-crew’ environment
therefore it possible to cross check information with, or hand over control to another
pilot if disorientation occurs. It is essential to recognize however that disorientation
may occur in both pilots at the same time and the importance of readily available,
accurate aircraft instrumentation.
“The instrumentation should present a clear and intuitive sense of position,

which the pilot under conditions of high stress and workload can instantly
achieve an idea of what the aircraft is doing.” (Newman, 2009)
The report discusses at length the integrity, layout and presentation of aircraft
instrumentation as well as clear and non-ambiguous indications of instrument failure.
It is recognised that the report is aimed at a general audience in aviation and Jetstar
A320 aircraft possess superior instrumentation systems that incorporate redundancy
and integrity monitoring systems. A question arises in the situation where
instrumentation becomes unserviceable prior to approach or during the approach
procedure as to whether accurate monitoring of remaining systems can be effectively
achieved. Currently Jetstar pilots adhere to a ‘minimum equipment checklist’ required
for initiation and continuation of RNP approach procedures. It is more restrictive than
normal ‘non-RNP’ operations and fulfils the requirement for adequate two pilot
approach monitoring.
Increasingly pilots are using a variety of vision enhancement devices including night
vision goggles (NVG) and heads up displays (HUD). Whilst these devices serve to
enhance situational awareness (SA) and reduce the possibility of an SD event, there
are additional safety implications associated with their use, such as cognitive
tunnelling (or attention tunnelling) and cognitive capture (Wilson, 1999). The benefits
and risks of these devices are detailed in other research that would warrant further
investigation if utilised. Jetstar A320 aircraft do not have additional vision
enhancement devices, and current procedures are deemed sufficient.
2.3.3 Operational Factors

Pilots need to be aware of the sort of flight operations that carry a risk of
disorientation. Frequently alternating between visual flight and instrument flight
increases the chances of confusion and disorientation, as does late switching to
instrument flight once IMC conditions have been entered – it takes time to establish
an instrument scan. Jetstar currently require pilots to conduct approaches using either
instrument or visual procedures, the PF nominates which procedures are to be used
based upon whether an instrument approach is needed/desired or not. The approach
procedures describe the required roles of the flight crew whilst the aircraft is on
approach and an explanation of each flight crewmember’s responsibilities and
task/role (Jetstar Airways Ltd, 2015).
Briefly, ‘instrument procedures’ require one pilot to remain ‘head down’ monitoring
instruments whilst the other pilot remains ‘head free’ monitoring external references
as well as instruments. If sufficient visual reference is established during the

approach, the PF may change the approach procedures to allow both pilots to become
‘head free’ enabling the head down pilot to look outside for external references also.
A caution is issued to pilots within this section of the Jetstar procedures to highlight
danger of ‘downgrading’ procedures at an inappropriate time on the approach that
may lead to confusion. These include:
Downgrading procedures close to the minima

As the aircraft reaches the minima for the approach there are numerous aural callouts
at key altitudes relating to the approach minima, and stabilized approach criteria, that
must be responded to appropriately. If the ‘head down’ pilot transitions to ‘head free’
close to the minima the pilot may not have time to comprehend their new role and
responsibilities at a time of high workload. There is a risk of task saturation and
procedural callouts being missed. It is prudent then to only consider downgrading
procedures at an area of the approach where workload is low and time is not critical.
Downgrading procedures when visual reference to touchdown is not assured

Downgrading procedures early in the approach when visual reference is not
absolutely assured may result in the aircraft entering IMC conditions again without a
‘head down’ pilot monitoring instruments. As stated earlier, swapping between visual
and instrument conditions increases the chances of confusion and disorientation; it
also takes time to re-establish an instrument scan rate. Finally, the report mentions
high workload situations when dealing with in-flight problems. If the coping ability of
the pilot or crew is exceeded an incapacitating disorientation may result.
2.3.4 Environmental Factors

The environmental factors mentioned in the report draw strong similarities to those
that will be experienced by pilots flying night operations into Queenstown. The major
environmental factors contributing to SD are related to time of day and ambient
weather conditions. Flight at night in poor weather conditions creates poor visual
cues, which are a function of most disorientation illusions. The location of the runway
at Queenstown, surrounded by high featureless terrain, and bordering a large lake and
sparsely populated land creates suitable conditions for black-hole illusion to develop.
False horizons4 may be seen when climbing out of weather and arriving on top of an
unrecognized sloping cloudbank.

4 Risk register numbers 42 & 53
2.4 Preventative Measures

It is important to emphasize to all crew that SD happens to normal pilots and if that
pilot flies for long enough eventually they will experience SD. Normal human
orientation systems are designed for use on the ground and not for flight, experiencing
an SD event should not therefore reflect a fundamental abnormality on the part of the
pilot. In saying this however, there are many preventative steps that can be taken prior
to flight that can minimize the risk of SD occurring. This involves understanding the
various pilot, aircraft, operational and environmental factors mentioned above and
applying preventative mechanisms to mitigate any likely risk. Some preventative
steps recommended in Newman’s report are listed below:
Health and Fitness to Fly:

• Pilots should only undertake flying duties when physically and mentally fit to
do so. CASA regulations and company policy requires individual
crewmembers to decide whether to fly or not and to seek guidance from
medical professionals where necessary5.
• Do not fly when under the influence of drugs (prescribed, over the counter, or
illicit drugs). If in doubt whether a type of medication may not be permissible,
consult your DAME6.
• Pilots should not fly whilst under the influence of alcohol, or whilst suffering
from the side effects of alcohol5.
• Pilots should ensure they have had adequate rest prior to the flight and are not
suffering from the effects of fatigue5.
• Pilots should ensure they are adequately hydrated and have eaten
appropriately prior to flight5.
• Pilots should manage their personal and professional stress appropriately, and
not fly when suffering from high levels of stress and anxiety5.
Planning and preparation

• Pilots should be aware of the potential for disorientation to occur at various
stages of their intended flight path and prepared appropriately. Pilots may
wish to address this as a potential ‘threat’ during departure and approach
briefings.
• Pilots should familiarise themselves with the characteristics of the destination
runway, especially if it is unfamiliar7 to them.
Training and education

• It is advisable for pilots to undertake regular in flight disorientation
demonstrations and upset/unusual attitude recovery practice
• If a disorientation event occurs, it is extremely helpful to share the experience
with other pilots. The more pilots are aware of disorientation, the more
prepared they can be. This can be achieved by reporting SD via the company
reporting system (OSCAR).

5 Risk register number 57, OM1 Section 4.32 Fitness to Fly & 5.2.1.3 Fitness for Flight Crew Duties
6 OM1 Section 4.33 Alcohol and Drug Usage & 4.34 Illegal Drugs
7
Risk register number 54
3. Effective Flight Path Monitoring
In 2014, the FSF Working Group (WG) published ‘A Practical Guide for Improving
Flight Path Monitoring’, a document that addressed concerns raised at the first
‘Human Factors Aviation Industry Round Table’ meeting in 2012. There was a
general consensus that although aviation incident/accident rates were at an all time
low, too many events were occurring that involved ineffective monitoring as a factor.
The WG critically analysed the wealth of information available through data streams
such as the line operations safety audit (LOSA), aviation safety action program
(ASAP), flight operational quality assurance (FOQA), flight data monitoring (FDM)
and US National Aeronautics and Space Administration (NASA) Aviation Safety
Reporting System (ASRS). The document identifies areas of weaknesses and gives
practical guidance to help improve the effectiveness to flight path monitoring.
The scope of the research was limited to monitoring of the aircraft’s flight and taxi
path because it is errors that result from deviations from these intended paths that may
lead to accidents. The WG identified the following barriers to effective flight path
monitoring (EFPM):
• Human Factors limitations;

• Time pressure;
• Lack of feedback to pilots when monitoring lapses;
• Design of flight deck systems and SOP’s;
• Pilots inadequate mental models of auto flight system modes; and
• A corporate climate that does not support emphasis on monitoring.
The recommendations of the WG includes guidance for aviation managers to enact

policy and procedures for elevating the role of monitoring on the flight deck,
comprehensive training guidelines and appropriate evaluation as well as advising an
operational culture of change. These items are outside the scope of this report;
however there are many areas of the FSF report that address concerns raised by the
JRRQ as well as specific guidance for pilot to aid in improving EFPM. The report
states that since 1994, data from focused accident research studies have confirmed the
positive contribution that effective monitoring makes in reducing error risk, and
catching errors, and the contribution that inadequate monitoring makes to serious
incidents and accidents (Flight Safety Foundation, 2014).
This report will look specifically at the human factors limitations of EFPM8 including
time pressure9 and how they relate to night operations at Queenstown.

8 Risk register numbers 23, 36, 42 & 53
9 Risk register number 60
3.1 Human Factors Limitations

The report highlights four barriers to EFPM that are a direct result of human
physiology:
The human brain has difficulty with sustained vigilance

Because modern aircraft typically have advanced auto flight capabilities and are
highly reliable, pilots often have little to do during the cruise but monitor for
occasional unexpected flight path changes or system anomalies that may occur. The
human brain has evolved for active engagement in individual tasks that are
challenging and stimulating, yet is less effective at monitoring for events that so
rarely occur. Extensive research in cognitive science has shown that the quality of
vigilant monitoring for rare events rapidly declines no matter how hard the individual
tries to maintain vigilance (Warm, Parasuraman, & Matthews, 2008).
The human brain has quite limited ability to multitask

The human ability to divide attention among tasks is quite limited and usually is
accomplished by switching attention back and forth among them, which leaves
individuals vulnerable to losing track of the status of one task while engaged in
another. The issue lays not so much in the total volume of work required as in the
concurrent nature of the task demands. Both pilots in the cockpit must often manage
multiple tasks concurrently, interleaving performance of several tasks, deferring or
suspending some tasks, while performing others, responding to unexpected
interruptions and delays and unpredictable demands by external agents (such as
ATC), and keeping track of the status of all tasks during these events. A review of
accident and incident reports from the NTSB and ASRS database, as well as
simulation studies reveal pilots are prone to error when performing ‘concurrent tasks’
(Loukopoulos, Dismukes, & Barshi, 2009).
Humans are vulnerable to interruptions and distractions

Following on from above, pilots engaged in concurrent tasks may become so
preoccupied in one task that they may inadvertently stop concurrently monitoring
another. Many aviation accident investigations have determined that the crew’s single
focus and attention on one task has led to the failure to monitor other important
aspects of flight. An often-used example of this type of distraction is the crash of
United Airlines Flight 173, where the aircraft crashed into a suburban Portland
neighbourhood due to fuel exhaustion whilst the flight crew attended to a landing gear
malfunction. Although the crew were all very highly experienced pilots, the NTSB
investigation determined that the probably cause of the fuel exhaustion was the
Captain’s inattention resulting from preoccupation with a landing gear malfunction
and preparations for a possible emergency landing (NTSB, 1979). Another form of
error occurs when pilots are interrupted and forget to resume the interrupted task.
Interruptions have been found to impair both individual and team performance
engaged in diverse tasks involving detailed procedures (Loukopoulos, Dismukes, &
Barshi, 2009).
Humans are vulnerable to cognitive limitations that affect what they notice and
what they do not notice
People are vulnerable to certain attention biases, such as not noticing one aspect of a
visual scene (e.g. mode annunciations on the FMA) while concentrating on another
aspect – a phenomenon called ‘inattention blindness’. Likewise, when a person’s
perception of a visual scene is momentarily disrupted, such as when looking away, the
person often subsequently fails to notice even large changes (‘change blindness’).
Also, individuals are vulnerable to thinking they see what they expect to see
(‘expectation bias’). Expectation bias is a considerably dangerous cognitive
impairment in critical phases of flight – pilots may glance at critical system
indications, such as landing gear position or a change in FMA annunciation, and
believe they are seeing what they would normally see at that particular stage of flight,
however an abnormal indication may be presented and not detected. This
phenomenon is colloquially known as ‘looking without seeing’ and is a result of
countless prior successful sequences causing complacency in effective monitoring.
3.2 Recommendations to Improve Monitoring Performance

Understanding barriers to EFPM is important for devising strategies for pilots to
evaluate their own performance limitations as individuals and as a crew, especially
those pilots performing night operations into Queenstown. Flight path monitoring
errors may result in deviations from the RNP flight corridor and towards high
mountainous terrain, or cause an unstable approach that could lead to a runway safety
(RS) event such as a long landing followed by runway excursion. Jetstar recognises
that elevating the monitoring role on the flight deck is a significant and worthwhile
operational objective.
The difficulty faced in improving EFPM is that the scope of factors affecting EFPM is
large and inextricably tied to innate human factors limitations as well as to system
design, task/workload management, fatigue, distractions, complacency and other
factors. Simply telling pilots to “do a better job monitoring” or “pay more attention”
will not work, and specific countermeasures that mitigate known barriers need to be
developed. The WG outline detailed recommendations in the report, but broadly
speaking the research recommends instituting practices that support EFPM by clearly
defining monitoring roles, establishing the concept of ‘areas of vulnerability’ (AOV)
where the potential for flight path deviation is higher than normal, managing
distractions, interruptions and non-normal situations and reinforcing the importance
of monitoring through training, safety promotion and company culture.
Many of the recommendations are recognised by this report to already be in effect at

Jetstar whilst others are outside of the scope of this investigation (safety promotion,
corporate culture, safety assurance etc) however it is considered worthwhile from a
human factors perspective to introduce the concept of AOV and apply it to the arrival
and approach procedures into Queenstown.
3.2.1 Areas of Vulnerability (AOV)

To perform EFPM during periods of high workload and increased vulnerability to
flight path deviations, it is imperative that pilots predict when and where these periods
will occur, and prepare for them. By ‘vulnerability’ the WG means either the
potentially increased likelihood of a flight path deviation or the increased severity of
potential consequences if such a deviation occurs (Flight Safety Foundation, 2014).
The WG categorises AOV into three distinct groups: low, medium and high. The
category is determined by the stability of the flight path, time available to detect
and/or correct flight path deviations and the consequences of flight path deviation.
The FSF apply the concept broadly to the whole flight detail from departure point to
destination however this report will apply the theory specifically to the RNAV arrival,
RNP approach and departure phases at Queenstown. Reviewing the arrival and
approach charts (see Appendix A) we can determine various points within the
procedure that may yield higher then normal crew workload due to a variety of
complex procedures occurring concurrently that require attention and thus increasing
vulnerability of flight path deviations. The charts serve as an example of some of the
hazards that may be presented during the approach and is non-exhaustive. The
premise behind the concept of AOV’s is to raise awareness so pilots can recognise
when they are entering these zones. The question now remains, what should crews do
(and not do) in each of these AOV’s? The FSF recommends two categories for action:
The first involves the ‘sampling rate’ of flight path monitoring; the second involves
workload management (Flight Safety Foundation, 2014).
3.2.2 Flight Path Monitoring ‘Sampling Rate’

Sampling rate (more commonly known by pilots as ‘instrument scan’) is the name
given to the specific items to be scanned during flight path monitoring depending on
the situational context. Whilst in flight, the items to be scanned certainly include the
flight instruments and associated flight guidance automation, however this may be
incorporated with monitoring items outside of the aircraft during VMC conditions,
such as weather phenomena or other traffic in proximity. It is important to highlight in
training the appropriate sampling rate with regard to the level of AOV, meaning the
higher the level of AOV the higher the required sampling rate. Whilst there are no
quantitative guidelines available, the FSF recommends this rule of thumb:
“The sample rate must be high enough that pilots would notice an indication
of deviation quickly enough to prevent a problem from getting out of hand”
(Flight Safety Foundation, 2014, p. 20)
The FSF offers the following definitions for EFPM sampling rates:
(See Appendix B for expanded definitions)
• A normal sampling rate is equivalent to the scanning frequency required

when hand flying an aircraft in straight and level flight;
• An elevated sampling rate is the scanning frequency required of a pilot hand
flying and aircraft approaching imminent change in trajectory or energy;
• A high sampling rate is the scanning frequency required of a pilot when hand
flying an aircraft through the execution of a significant change of trajectory or
energy.
(Flight Safety Foundation, 2014, p. 20)
In Jetstar multi-crew operations the division of workload between flight deck

crewmembers will also influence the sampling rate. If for example one crew member
goes ‘head down’ to program the FMGC during flight the sampling rate of the other
crew member must go up to compensate. It would be appropriate during training to
address priorities and appropriate actions of crewmembers during times of high AOV.
Refer to the table in Appendix B for further explanation of sample rate and
task/workload management required within various levels of AOV.
3.2.3 Task/Workload Management in an AOV10

As mentioned previously, the human brain has difficulty with sustained vigilance and
has limited ability to ‘multitask’ (or more correctly to perform ‘concurrent tasks’).
Monitoring the flight path therefore requires some portion of the pilot’s limited
available mental capacity. If the pilot attempts to perform other non-flight path related
activities it will require more of the total capacity available. Attempting too many
tasks simultaneously may exceed total available mental capacity (task saturation)
increasing the risk that the monitoring task will be omitted. To ensure adequate
attention is available for EFPM in all AOV’s, task management of non-flight path
tasks is critical.
For example:
The final approach phase of flight onto RWY 23 has been designated with ‘High
AOV’ and would therefore require a ‘high sampling rate’ and specific task/workload
management from both crewmembers. During the approach the control tower clears
the aircraft to land and gives updated wind, temperature and surface conditions for
information, which are noted to be minor changes in detail. It would not be prudent
for the PM to suddenly go ‘head down’ and alter the performance landing data in the
FMGC at such a critical stage of flight, significantly increasing required sampling rate
and workload of the PF. Such tasks could be performed in an area of lower AOV
where workload and required sampling rate allow such an action to be completed
safely. The designation of ‘High AOV’ leaves no doubt as to the roles and
responsibilities of both pilots with regard to monitoring the flight path of the aircraft
during this critical phase, and managing distractions responsibly.

10
Risk register numbers 9, 23, 36, 46, 47, & 54
4. Threat and Error Management
4.1 Introduction to TEM Models

Threat and error management (TEM) is a model frequently raised when discussing
flight safety, especially when referring to flight deck operations. It has evolved
gradually as a result of an ongoing effort to improve safety margins through practical
integration of HF knowledge. TEM is a conceptual framework that assists in
understanding, from an operational perspective, the inter-relationship between safety
and human performance in dynamic and challenging operational contexts (Maurino,
2005).
It is the position of this report that Jetstar pilots already have an awareness of the
TEM model; it’s application as an analysis tool during accident/incident investigation
or LOSA audits (in which Jetstar participates) and in the understanding the definitions
of threats, errors and undesired aircraft states (UAS). During Jetstar departure or
approach briefings, pilots are required to include an interactive discussion of the
potential threats to the flight, and strategies to mitigate these threats (Jetstar Airways
Ltd, 2015). LOSA audit findings are also disseminated to flight crew via operational
memos and ground training to highlight areas of heightened threat and error
occurrences and to review mitigating techniques and strategies.
4.2 A Systemic Approach to Mitigating Strategies

The JRRQ identified crew errors, mistakes or violations in nineteen11 areas of the
report with potential hazards spanning, incorrect barometric setting, loss of
separation, turnaround time pressure (forced errors), loss of situational awareness,
and intentional violations. Whilst each of these hazards could be examined
individually with specific mitigating strategies put in place, it is prudent to take a
more holistic approach to threat and error mitigation techniques that promote
appropriate CRM behaviours and shared mental models that have been proven to lead
to successful outcomes. Simply preparing for expected threats is not sufficient.
Regardless of whether threats are expected, unexpected, or latent, the effectiveness of
a flight crew’s ability to manage threats is whether they are detected with the
necessary anticipation to enable the flight crew to respond to them through
deployment of appropriate countermeasures (Maurino, 2005).
Section three (EFPM) introduced concepts developed by the FSF that can greatly
assist in threat mitigation, situational awareness and task/workload management
during phases of flight where crew are more vulnerable to committing errors. TEM
techniques can be applied broadly to the entire operation and is not limited to flight
crew activities, but may also include cabin crew, ATC, ground crew, the flight
operations department and any other areas of the company that have a sphere of
influence over operational safety.
For example, feedback from the Jetstar LOSA audit performed in 2014 revealed the
highest rate of errors occurred in the ‘pre-departure’ phase of flight (all flight duties
prior to aircraft pushback). The highest threat category encountered was ‘crew
support’ which predominantly affected flights in this pre-departure phase, especially
in areas of crew distraction/interruption or incorrect terminology (Finlay, 2015). The

11 Risk register numbers 9, 11-‐13, 16, 23, 25-‐27, 36, 38-‐41, 49-‐52 & 60
pre-departure phase of flight involves critical tasks such as weight, balance and
takeoff performance calculations, as well as requesting air traffic control clearances,
conducting data and fuel checks and a takeoff briefing. It is clear that an error in
calculating critical performance calculations could have disastrous consequences if
not recognised so crew must employ appropriate TEM strategies to mitigate threats
and trap errors. Strategies would include pilots having a clear understanding of the
types of threats (by category) they may face and the CRM behaviours required to
enable recognition of threats to avoid making an error and detecting when an error
has occurred and successfully managing the recovery.
The LOSA research group have developed a general model of threat and error in
aviation. The model is reproduced in Appendix C and indicates that risk comes from
both expected and unexpected threats. Expected threats are those that are obvious to
the crew, for example: high terrain, inclement weather and poor runway conditions.
Unexpected threats include those that are unanticipated by crew, such as unreasonable
ATC instructions, system malfunctions or operational pressure. External errors
include those that are made outside of the cockpit, for example by maintenance, ATC
and flight dispatch. Crew’s themselves may err in the absence of any external
precipitating factor (internal threat), however both external and internal threats are
countered by the defences provided by CRM behaviours. CRM behaviours stand as
the last line of defence and when successful, lead to a safe flight. If the defences are
breached, they may result in additional error or an accident or incident (Helmreich,
Klinect, & Wilhelm, 1999).
The LOSA group have also classified and defined error in the aviation context.
Operationally, flight crew error is defined as crew action or inaction that leads to
deviation from crew or organisational intentions or expectations (Helmreich, Klinect,
& Wilhelm, 1999). Referring to the error management model in Appendix D, once
flight crew error has been identified, the resulting classification pathway can be
tracked to monitor crew response, error outcomes, UAS occurrences and subsequent
management of the UAS. This epidemiological system of taxonomies facilitates
analysis of all aspects of error, response and outcome. The failure or success of
defences such as CRM behaviours can also be evaluated.
4.3 TEM and Jetstar

The TEM investigation philosophy has been embraced by Jetstar Airways and is
evident in its application to operational occurrences by way of the Company
Investigation Policy outlined in the Jetstar SMS Manual (OM9) and Jetstar Airline
Policy Manual (JAPM). Through it, human error and subsequent management is
mapped using the Jetstar Causal Framework and forms part of the investigation
process that follows closely those outlined in the TEM model. The investigation
process and outcomes form an integral part of Jetstar Safety Assurance program, a
pillar of the Jetstar Airways SMS. Results are ultimately analysed for inclusion in
flight simulator and ground training programs to aid in improving successful CRM
behaviours. In addition, to aid Jetstar pilots in understanding threats and errors
occurring on regular line flights the Flight Operations Safety Investigation application
is available on pilot issued company iPads. The application enables pilots to view a
sample of completed investigations to raises awareness of operational hazards, the
CRM behaviours that occurred and the outcomes achieved (whether successful or
unsuccessful). This flow of information promotes honest conversation with other
crewmembers on the topic of threat and error management and an awareness of the
requirement for sustained vigilance towards threats to operational safety.
In addition to Jetstar training programs, Jetstar operations manuals reiterate the

importance of following SOP and managing distractions to safe flight operations
(Jetstar Airways Ltd, 2016). Although there is no ‘magic bullet’ for eliminating
operational threats and errors, there is clear evidence that core behaviours of CRM
serve in risk avoidance and error management. Jetstar recognizes the inevitability of
error and continues to concentrate on management of threat and error and strategies
to reduce the consequences of errors and mitigate UAS.
Appendix E includes mitigation strategies that outline proven techniques to

overcome normal human limitations that may erode safety margins. Compiled by
flight safety investigators Alan Dean and Shaun Pruchnicki, they feature in various
flight safety guides including the FSF AeroSafety World Magazine. It is felt that the
strategies presented in this list provide an excellent summary for pilots who wish to
refresh themselves in TEM techniques and may be considered for inclusion in TEM
training at Jetstar.
4.4 Incapacitation
Pilot Incapacitation is the term used to describe the inability of a pilot who is part of
the operating crew to carry out their normal duties because of the onset during flight
of the effects of physiological factors (SkyBrary, 2014). Incapacitation was indicated
as a specific hazard in several areas of the JRRQ12 resulting in increased workload on
the remaining crewmember thus significantly reducing safety margins.
A 2006 study conducted by Dr David Newman for the ATSB, concluded that the
number of events where pilot incapacitation caused and incidents or accidents was
low (0.6% of all events in the database between 1st January 1975 and 31st March
2006), however the majority of events occurred in airline operations (Newman, 2006).
The report revealed that the majority of incapacitation events for Australian civil
pilots were acute gastrointestinal illness (21%), usually food poisoning. This was
consistent with similar studies including that of US airline pilots where the same
illness led all other causes, being present in 58.4% of in-flight incapacitations (James
& Green, 1991).
Newman’s study did not elaborate on what stage of flight incapacitation occurred, yet
James & Green stated the most common phases of flight were en-route (42.1%),
followed by climb (18.4%), descent (17.3%), and on the ramp (11.4%). Safety-of-
flight was felt to be potentially affected in 45% of cases and definitely affected in 3%
of cases. Of those reporting that safety-of-flight had been affected, 43% stated the
incapacitation event placed the remaining aircrew under maximum workload (James
& Green, 1991). Both studies mentioned the risk of sudden incapacitation due to
myocardial infarction (heart attack) although the subsequent risk of incident/accident
is low in two pilot operations where another pilot is able to assume control.
Although research shows the probability of an incapacitation occurring is low, Jetstar

training material describes flight crew incapacitation as a real safety hazard that

12
Risk register numbers 10, 24, 37, 48 and 57
occurs more frequently than many of the other emergencies (Jetstar Airways, 2015).
The FCTM describes the various types of incapacitation, from sudden death to partial
loss of function, and lists the required actions once incapacitation of a fellow
crewmember has been detected. Initial responses include assuming immediate control
of the aircraft and disconnecting the controls of the incapacitated pilot to reduce
possible interference. The key to effective management of an incapacitation scenario
is ‘detection’, as the incapacitation of flight crew may not be immediately apparent.
Research performed in aircraft simulators yielded some interesting results in tests
where flight crew were subjected to both sudden and subtle incapacitation events. The
average time to detect subtle incapacitation was 1.5 minutes and 25% of the simulator
events ended in aircraft accidents (Dejohn, Wolbrink, & Larcher, 2006).
The Jetstar Administration Manual describes the need to maintain strict adherence to
SOP and normal flight regimes in order to readily identify any deviations. A policy is
outlined where if any abnormal flight situation is observed by either crewmember
then this should be challenged and an appropriate response must be heard (and
appropriate action initiated). If no response is heard then a second challenge must be
made, if there is still no response the challenger must assume immediate control of the
aircraft and return it to a safe operating envelope (Jetstar Airways Ltd, 2016). After
securing the safe flight path of the aircraft and following the procedures outlined in
the FCTM, it is noted that there is only very ‘general guidance’ with regard to the
decisions over continuation of flight and landing aerodrome. The FCTM phrase ‘Land
at the nearest suitable airport after consideration of all pertinent factors’ could be
considered quite subjective and relies heavily on the remaining pilot making the
correct decision under possible conditions of high stress and task/workload saturation.
It would be prudent to discuss incapacitation events in various stages of flight (i.e.
cruise, approach, short final, landing roll, etc) and decision-making around the
pertinent safety issues. For example, there may be an overwhelming urge to land the
aircraft immediately in order to get medical attention for the incapacitated
crewmember, however one must also consider the safety of all other crewmembers
and passengers on board the aircraft. The correct decision may include taking the time
to divert to an aerodrome where a safe landing can be assured especially when
considering the additional hazards of landing during night hours at Queenstown.
4.5 Unstable Approaches and Runway Excursions13

Runway safety (RS) events continue to dominate accident and incident statistics with
high proportions of jet aircraft involved in runway excursions and incursions,
undershoot/overshoot, tail-strike and hard landing events. Recent safety statistics, that
include harmonised data streams from both IATA and ICAO, reveal that RS events
outnumber all other accident categories (IATA, 2015). A breakdown of these RS
events shows that the majority of occurrences occur in turbofan (jet) aircraft during
the landing phase of flight. Recognising this emerging trend, the FSF is currently
engaged in an ongoing safety initiative to address the challenge of runway safety. A
runway safety initiative report released by the FSF also identified that runway
excursions are dominant in RS events, with the main culprit being jet aircraft in the
landing phase of flight (FSF, 2009). Throughout these safety reports, a factor
identified as significantly contributing to runways excursion on landing is the crew’s
failure to conduct a go-around from an unstable approach.

13
Risk register numbers 9, 23, 36 & 47
A stabilised approach is where specific criteria stated in company SOP’s is met

before, or when, the aircraft reaches the applicable minimum stabilisation height. The
criteria for a stabilised approach recommended by the FSF is outlined in Appendix F
and requires the aircraft to be within certain normal performance and flight path
envelopes with all crew briefings and checklist procedures complete. The benefits of
stabilised approach criteria include; increasing the flight crews overall awareness of
the aircraft flight path, rate of descent, airspeed and energy state whilst providing
more time for monitoring ATC, weather conditions and systems operation; clearly
defining parameter deviation limits, and creating landing performance conditions
consistent with aircraft design calculations.
Jetstar policy requires all approaches to be ‘stabilised’, with criteria outlined in

company FCOM closely aligned with the parameters recommended by the FSF.
Standard phraseology is used to bring any deviating parameters to the PF’s attention
where an immediate correction must be made or a go-around initiated. Jetstar employs
a ‘no-fault’ go-around culture and encourages crew to be ‘go-around’ minded,
recognising the risks involved with continuing an unstable approach. Strict adherence
to SOP with regard to stabilised approach criteria is crucial in reducing the likelihood
of RS events, however current safety statistics show that high numbers of RS events
occur due to continued unstable approaches. In Australia, whilst the number of RS
events is low, all runway excursion accidents and serious incidents involving
Australian registered commercial jet aircraft have involved unstable approaches
(ATSB, 2008).
Research conducted by Airbus and the FAA has shown that although unstable
approaches are rare (only three to four percent of all approaches) only two to three
percent of unstable approaches end in a go-around (Donoghue, 2012). The FSF found
that the following behaviors are often involved when unstabilised approaches are
continued:
• Excessive confidence in a quick recovery (postponing the go-around decision

when flight parameters are converging toward excessive deviation limits);
• Excessive confidence because of a long and dry runway and a low gross
weight, although airspeed or vertical speed may be excessive;
• Inadequate preparation or lack of commitment to conduct a go-around; and
• Absence of decision making (failure to remember the applicable excessive
deviation limits) because of fatigue or workload.
(Flight Safety Foundation, 2009)
The following points were also raised as influencing the decision to go-around:
• Unsafe behaviour being reinforced when successful landings are completed
after continuing an unstable approach;
• Pilots motivated by pride or company pressure to ‘get the job done’;
• Pressure due to reduced fuel loads at arrival destinations;
• Issues of fatigue, which boosts the ‘need’ to get down while diminishing the
pilot tools available to achieve the desired outcome;
• Inadequate training on stabilised approaches, go-around procedure, and CRM,
that avoid getting into situations where a go-around is necessary;
• Inadequate management response to evidence of high rates of unstable

approaches and low rates of go-arounds;
• Inadequate management knowledge about the state of operations, i.e., absence
of monitoring programs in place, or poorly executed; and
• Pilots do not feel empowered to call for a go-around. Airline policies should
not penalise pilots who decide to go-around, whether it is the PF/PM, Captain
or First Officer.
(Donoghue, 2012)
It is important to recognise the behavioural traits that influence decision-making at

this critical stage of flight. Whilst Jetstar enforce strict stabilised approach criteria and
provide a just culture that promotes a go-around minded approach environment, it is
important for pilots to be made aware of the HF traits and operational environments
that may influence their decision, and the risks associated with continuing unstable
approaches.
The following technique is recommended by the FSF as an accident prevention

strategy and personal line of defence to prevent continued unstable approaches:
Anticipate – Detect – Correct – Decide
Anticipate Anticipate factors that are likely to result in an unstable approach and
brief strategies to mitigate these threats. Have an agreed management
strategy for the approach and a common objective. A change of
mindset should take place from “we will land unless…” to “let’s be
prepared to go-around, and we will land if the approach is stabilised
and if we have sufficient visual references to make a safe approach and
landing”.
Detect Have a good understanding of the defined stabilised approach criteria;

use standard phraseology to bring deviations to the attention of the PF
in a timely manner. Avoid non-pertinent conversation and unnecessary
actions to ensure adequate flight path monitoring.
Correct Positive corrective action should be taken before deviations develop

into a challenging or a hazardous situation in which the only safe
action is a go-around.
Decide If the approach is not stabilised before reaching the minimum

stabilisation height, or if any parameter exceeds deviation limits (other
than transiently) when below the minimum stabilisation height, a go
around must be conducted immediately.
4.6 Procedural Drift14

Procedural drift (also known as practical drift, operational drift or normalised
deviance) is the term given to the departure of front line operational performance,
from baseline-planned performance. It is due to a perceived incompatibility between
safety procedures put in place by subject matter experts and the actual procedures
required to execute the task. In this situation, the ‘end user’ develops an alternative
procedure (a safety shortcut), which may not initially result in any negative feedback,
reinforcing their perception that the alternative procedure is correct (false feedback).
The result is an uncoupling of written procedure and the way in which work is done
on the front line that if left untreated may result in disaster (Fry, 2015).
An example of procedural drift could be:

The policy for aircraft exterior safety inspection says: An exterior inspection cannot
be completed until the gear pins and covers are removed by aircraft engineers and
stowed on the flight deck. This is to ensure they are removed prior to departure to
enable gear retraction and crosschecked by crew during the inspection. A flight crew
under time pressure may decide to perform the inspection whilst the pins are installed
to save time and rely on the engineer to perform his tasks correctly. The flight then
leaves on time without any problem. This positive outcome reinforces to the crew that
they made ‘the right decision’ (false feedback). The next time they are put under time
pressure they may revert again to this alternative procedure, remembering how well it
worked the last time. This alternative procedure has now become ‘the norm’ and may
be passed along to other crewmembers as ‘the way we do things to get the job done’.
There now exists a dangerous situation (latent threat) where if the engineer does not
remove the pins in time (active failure) the aircraft may depart with the gear pins and
covers still in place and the landing gear unable to be retracted after takeoff.
The above example can be applied to any area of the business where safety policy and
procedure must be followed to ensure operational integrity. It is important to
understand the inevitability of human nature in changing procedures to create
efficiencies and take ‘safety shortcuts’. This is especially prevalent in complex,
tightly coupled systems where there is a conservative approach to rule making (over
design) to prevent accidents from occurring, and also in large organisations that try to
create uniform sets of rules across many different systems that require local
adaptations. The aviation industry certainly lends itself to creating areas where
procedural drift could occur. It is a highly regulated environment that requires strict
adherence to policy and procedure to ensure adequate safety margins are in place at
all times. SOP’s promote a harmonised set of procedures that provide an environment
of shared understanding and commonality that allows pilots who have never met
before to operate together with ease and uniformity. A problem only arises when you
consider the operational diversity involved with operating aircraft to the same set of
procedures that are required to be applied uniformly whether flying in South East
Asia or the Southern Alps of New Zealand.
James Klinect director of the LOSA collaborative has stated that on 49% of the flights
in the organisational archive, at least one intentional non-compliance error had been
observed. The real problem, he added, is that flight crews often respond incorrectly to
an intentional noncompliance error — that is, their response actually represents a

14
Risk register numbers 9, 23, 36, 47 & 60
mismanagement of the error — about 20 percent of the time, “so 20 percent of

intentional noncompliance errors are actually linked to other errors.” (Werfelman,
2013). This statistic reinforces that non-compliance (or procedural drift) exists in
aviation and is a measurable threat. Both ‘rule makers’ and ‘end users’ alike must
address it, as mitigating the threat of procedural drift is a shared responsibility.
Jetstar currently have procedures in place to enable notification of procedural drift by

way of the ‘Normalised Deviations/Workarounds Feedback Form’ available to all
pilots on company issued iPads. The form is confidential in nature and is forwarded to
the Jetstar HF department for assessment and used by the Jetstar Flight Events
Working Group (FEWG) to identify and address systemic risk in flight operations.
This system allows an opportunity for pilots to provide feedback on policy and
procedures that, for whatever reason, are not perceived to serve the best interests of
safety and efficiency and require further investigation for reasonable alternatives to be
developed. Any issues that require more immediate attention can be notified by
OSCAR or alternatively, the pilot may contact the Duty Captain.
As some procedures pertaining to night operations into Queenstown will be new to

both pilots and management staff designing these procedures, it will be important to
refresh pilots involved in these operations of the risks involved with procedural drift
and the requirement to notify Jetstar of known issues via the appropriate method. It is
also important for management pilots and rule makers to engage with front line pilots
to gauge the effectiveness of procedures and consider any changes that need to be
made. This positive approach to procedure design and rule making will allow for
effective feedback and avoid the latent threat of procedural drift and intentional non-
compliance.
5. Startle Effect
The aviation industry has benefited from significant advances in technology that has
led to the inherent safety and reliability of modern aircraft. Data released by ICAO
shows that the global accident rate for 2014 was three per million departures and the
number of fatal accidents decreased to seven, the lowest in recent history (ICAO,
2015). When viewed in contrast with vehicle accident rates or deaths through medical
misadventure, the scarcity of aircraft accidents shows an industry that has ultra-high
reliability and robust resilience to systemic and individual failures.
Unfortunately, this universal acceptance of reliability has resulted in a conditioning of

normalcy amongst pilots that may contribute to underperformance during surprise
critical events (Martin, Murray, & Bates, 2012). A number of accidents have occurred
in recent years where adverse pilot performance following startle may have either
contributed or been directly causal. Some notable examples are:
Air France Flight 447, where the BEA investigation found that the initial response of
the First Officer to pull up hard on the control stick was consistent with impaired
information processing, decision making and problem solving, typical of a startle
reaction.
“The excessive nature of the PF’s inputs can be explained by the startle effect
and the emotional shock at the autopilot disconnection, amplified by the lack
of practical training for crews in flight at high altitude, together with unusual
flight control laws.” (BEA, 2012, p. 173)
Colgan Air Flight 3407, where the Captain inappropriately responded to an aircraft
stall by pulling back on the controls (fighting against the actions of the stick pusher)
whilst only applying around 75% of available power. At the same time the First
Officer retracted the flaps to zero further exacerbating the aerodynamic stall. Both
crew members demonstrated confusing actions that was contrary to any and all
previous stall training and could very well have been induced by physiological effects
caused by startle reaction.
“The NTSB concludes that the captain’s response to stick shaker activation
should have been automatic, but his improper flight control inputs were
inconsistent with his training and were instead consistent with startle and
confusion.” (NTSB, 2010, p. 89)
In contrast to these events however, there are examples of occurrences where pilots
have performed exceedingly well. The catastrophic engine failure aboard Qantas
Flight 32, or the dual engine failure of US Airways flight 1549 serve as examples of
flight crew who when placed under immediate pressure to react, have responded
appropriately as individuals and as a team. Obviously the aim of any training system
is to produce pilots who demonstrate these positive human characteristics and there
has been some discussion over how this will occur. As startle effect is a relatively
new concept with regard to aviation human factors much of the research has yet to be
translated into effective training. It is considered pertinent however to include this
information to pilots engaged in night operations into Queenstown due to the
complexity of the operation and the severe consequences of inappropriate startle
reaction. Also, employing some recommended training techniques might prevent

pilots reacting negatively to startle effect and/or enable crew to identify startle in one
another and act to reduce or reverse any negative responses. The following sections
explain broadly how startle effect occurs, how it manifests itself through
inappropriate responses and what can be done to mitigate it’s affects.
5.1 The Startle/Surprise Reaction

It is important to recognize that the startle reflex is common to all mammals, birds,
reptiles and amphibians. It is an innate and involuntary reaction to some startling
stimulus, which can be perceived in any sensory modality (Martin, Murray, & Bates,
2012). Research into startle response shows that when humans are subjected to a
startle event there are various neural pathways involved that trigger a response. The
amygdala (in the limbic region of the brain) processes the sensory signals for a
rudimentary interpretation of the emotional valence whilst other signals are sent via
the pre-frontal cortex for cognitive processing. The problem lies in that the amygdala
processes information very quickly (14 milliseconds) whilst the pre-frontal cortex
may take in excess of 500 milliseconds (indicated respectively in figure 3 below by
the ‘low road’ and ‘high road’). The result is that initially the human response is to
react aversively to the stimulus whilst at the same time immediately focusing
attention on it. This initial response may last anywhere between 0.3 and 1.5 seconds
(depending on the individual and severity of the event) however the situation worsens
if the threat persists, and the startle transitions from a simple aversive reaction to a
full-blown startle or surprise reaction. What follows is the activation of various
systems that engage the ‘fight or flight’ reaction, which affects heart rate, blood
pressure, and respiratory rate whilst directing blood flow away from the extremities of
major muscle groups. This process contributes to the confusion or delays processing,
commonly experienced during strong startle (Martin, Murray, & Bates, 2012).
Figure 3: Tracing emotional pathways (LeDoux, 1996)
To summarize, the brain has evolved to react quickly to events that pose an immediate
threat to safety at the expense of normal rational thought. It is a process designed
purely around self-preservation where time is considered the most important factor.
The human body has evolved over thousands of years whilst aviation (and other
industries) has developed at an exceedingly high rate over the last century placing
demands on human physiology for which it has not had time to adapt. Consider the
high rate of vehicle accidents that occur when drivers swerve to avoid animals on the
road, only to collide with oncoming traffic. Simply telling pilots to ‘think before you
act’ is not enough, as our brain cannot be ‘rewired’ so easily. An understanding of
how the brain functions when exposed to unexpected events is essential for pilots to
understand this human limitation. Awareness of startle effect enables appropriate
training to be developed and allows crew to contemplate their own personal
limitations as well as being able to identify its affects in others.
Based on the findings of this report it would be considered highly beneficial for the
training department to develop scenarios that include unscheduled and unanticipated
events that attempt to induce a startle response. Research by Griffith University
attempted to create such a scenario by introducing unexpected stimuli at a critical
phase of flight, then recording how the crew reacted. A cargo fire bell and loud bang
was introduced during an instrument approach at 40ft above the approach minima.
Even though the crew were type rated, experienced and operating in a modern jet
airline environment, the results showed that only one third of crew responded
appropriately whilst the remaining crew had delayed reactions, did not react
appropriately (breached SOP, triggered GPWS, incorrect go around procedure, etc) or
reacted impulsively (Martin, Murray, & Bates, 2012). Unfortunately, it is recognised
that the ‘startle effect’ is difficult to create in a training environment and/or maintain.
The scenarios soon become known to the trainees, giving them the opportunity to
prepare for the failures in advance. In this context, the instructors have an important
role to play. The investigation of Air France Flight 447, the BEA included the
following statement in its findings:
“Exercises performed in a simulator follow a predetermined scenario, and even if

there are variations from one session to the next, the trainees are more or less
familiar with the failures they will have to deal with. In this respect, the training
scenarios may significantly differ from the reality of an in-flight failure. The startle
effect associated with this operational reality is destabilising and generates stress. It
may have a direct impact on the correct execution of a manoeuvre, or on the ability of
a crew to diagnose the problem and then recover the situation. However, the
conditions in which training is delivered are not conducive to giving instruction in
these environmental factors, and thus to the subsequent application in service of the
non-technical skills necessary for the correct management of an unexpected
situation” (BEA, 2012, p. 185-186)
There is a great deal of further research and education to be completed in this line of
HF training, however the recent study undertaken by Martin, Murray, & Bates
concluded that providing training for pilots in handling unexpected critical events will
likely have two benefits: It will raise expectations for such events; and provide pilots
with both generic and specific skill-sets for handling them.
6. Conclusion
Flight operations at Queenstown during night hours pose many risks to safe flight
operations. This is due in part to flight paths utilising modern technology in
navigation and automation that allows aircraft to fly closer than ever to mountainous
terrain. Pilots must remain extremely vigilant to a large number of threats presented
during this type of operation whilst closely monitoring the flight path of the aircraft
and concurrently managing many other important operational requirements. This
highly demanding environment may push the limits of human capability where it is
recognised that the consequences of human error are higher than in more benign
operational environments. This report served to address key areas of concern raised
by the JRRQ and flight safety agencies in order to mitigate known risk and provide
information to pilots to heighten awareness.
Areas of concern include the effects night operations may have on pilots due to
reduced visual stimuli and related spatial illusions caused by our human physiology.
Aviation accidents were shown to be more prevalent at night than during daylight
hours due to optical illusions combined with an increased chance of fatigue. Causes of
spatial disorientation were discussed with the phenomena of ‘black hole effect’
identified as being very likely to be encountered. Preventative mechanisms identified
by the report included highlighting pilot health and fitness to fly, specific planning
and preparation techniques and specific training and education.
Effective flight path monitoring brought to light certain conflicts between the
increasing requirements for pilots to remain vigilant during approach, whilst
concurrently monitoring many other aspects of the operation, and the human factors
limitations that inhibit pilot’s ability to sustain this process effectively. It was found
that human limitations exist that affects a pilot’s ability to remain vigilant, perform
concurrent tasks, avoid interruptions and clearly recognise when things are changing
around them. Studies performed by the FSF recommend employing various
techniques to improve flight path monitoring and task/workload management. This
included establishing ‘areas of vulnerability’ where pilots are made aware of the
potentially increased likelihood of flight path deviation or the increased severity of
potential consequences if such a deviation occurs. The technique was applied to
approach and departure operations and presented as an example of how AOV
allocation may heighten awareness and reduce the chance for errors to occur.
Threat and error management was addressed in section four which covered certain
TEM models developed by the LOSA collaborative to aid in classifying types of
threats, errors and undesired aircraft states. It was found that whilst EFPM could be
applied specifically to the approach and departure phases of flight to mitigate threats,
TEM could be applied more generally over all areas of the operation to allow pilots to
identify threats and apply appropriate mitigating strategies. It was acknowledged that
TEM techniques are currently addressed in the Jetstar training syllabus yet more
effort could be made to significantly reduce the amount of interruptions and
distraction inflicted upon flight crew during the pre-departure phase of flight. When
faced with expected or unexpected threats, the data showed that CRM behaviours and
shared mental models were proven to lead to successful outcomes.
A specific concern raised in the JRRQ was the threat of pilot incapacitation. Whilst
incapacitation of flight crew was shown to occur very rarely in flight operations,
occurrences that do occur will substantially increase workload requirements of the
remaining pilot, which may lead to task saturation and poor decision making. In
addition, the consequences of misidentifying incapacitation were high with simulator
research revealing alarmingly high rates of incapacitation events ending in an
accident. Jetstar already identifies incapacitation as a real threat to safety and
incapacitation training in simulators is supplemented by guidance in training manuals
and ground course material. It was found that the best method of detection is strict
adherence to SOP and normal flight regimes. This includes CRM techniques where
crew can challenge unusual actions or breaches of policy, and require an immediate
response. An area of improvement was identified where decision making of the
remaining pilot after an incapacitation event may be impaired by high workload and
task saturation. It was recommended that further discussion during training be
required to make crew aware of decision-making techniques during incapacitation
events that take into account the safety of remaining passengers and crew.
Continuation of unstable approaches was revealed to contribute heavily to runway

safety events according to statistics released by top global safety agencies and this
issue was addressed also in section four. Jetstar policy was found to promote a ‘no-
fault’ culture with regard to missed approaches and pilot training requires crew to be
‘go-around minded’ as well as ‘go-around prepared’. The evidence shows however
that whilst policy may encourage a certain type of behaviour, individual human traits
as well as internal and external pressures may cause poor decision making at this
critical phase of flight. It is therefore essential to emphasize the importance of
detecting when an approach is unstable and reacting appropriately by executing a go-
around.
Procedural drift, where work being done on the front line differs to that which is
stipulated by the company rules, could be an issue at Queenstown due to the unknown
nature of this new endeavour. Certain situations unique to night flying at Queenstown
may require actions from crew that fall outside the scope of normal procedures and
crew need to be made aware that this information must be fed back to management
via the appropriate channels. It was found that current procedures such as
‘workarounds feedback’ and ‘OSCAR’ forms are sufficient, however crew could be
refreshed of this feedback requirement whilst managers/rule makers could also be
active in engaging with front line staff.
The final section reviewed a relatively new area of HF research, the startle effect. It
was found that the increased reliability and inherent safety of aviation systems has led
to an unfortunate conditioning of pilots to expect things to always function without
error. As automation has become so reliable, pilots are forced more into a
‘monitoring’ role and risk a feeling of disconnection from the process. This has
resulted in pilots underperforming during surprise critical events and has been
identified as a contributing factor to many recent aircraft accidents. Surprise/startle
reaction was found to be a function of the brains emotional response process designed
for self-preservation during perceived threats to safety. Whilst the safety community
has identified startle as a contributing factor, little research has translated into
effective training techniques. Conditioning pilots to expect startle events by creating
them in the simulator is deemed very difficult to achieve as pilots become aware of
the scenarios and can prepare. This report advises that further discussion be had over
possible training techniques and the inclusion of startle factor information to pilots
during ground training. Knowledge of startle factor events and how it has affected the
outcome of aircraft accidents raises awareness of the issue and allows pilots to
develop specific skill-sets for handling them.
7. Recommendations
Based on the findings of this report, the following recommendations are presented for
consideration:
• Provide training and guidance around Spatial Disorientation, the emphasis

being that SD events can occur to any pilot regardless of their experience.
This includes an awareness of the contributing factors and preventative
measures that will allow crew to recognise when SD is likely to occur,
enabling them to prepare appropriately or react accordingly if it does. This
may involve (but is not limited to) including specific SD information in
ground courses, practising SD events in the simulator, discussing SD on line
training flights and encouraging crew to share their SD events with others via
the OSCAR reporting system.
• Review the information recommended in Section 3 of this report by the FSF

on Effective Flight Path Monitoring. Whilst it is recognised that current Jetstar
procedures are adequate, Jetstar should be proactive in including proven
effective techniques to improve flight path management. The implementation
of AOV’s along with associated ‘sampling rate’ and ‘task/workload
management’ techniques have been proven to mitigate many of the recognised
human limitations that cause aviation incidents/accidents.
• Threat and error management continues to be an essential part of the Jetstar

training syllabus. Whilst knowledge of TEM models and understanding the
various taxonomies of error is helpful for statistical evaluation and aids in
improving training programs, it in itself does not improve a pilot’s ability react
appropriately when the unexpected occurs. Pilot’s need to be made aware of
the areas of Jetstar operations that are most likely to present threats (expected
threats) but also taught to remain vigilant towards unexpected threats. It will
be important to emphasise that the best defence mechanism to combat threats
is positive CRM behaviours. Appendix E lists a number of proven strategies
that can be integrated into the flight-training syllabus where appropriate.
• Further procedure and training to be delivered to pilots with regard to decision

making in the event of incapacitation. Specifically, how decision-making is
affected under high stress and workload and safe courses of action when
considering continuing or diverting the flight.
• Reinforce through ground and flight training regimes the importance of

stabilised approach criteria and the risks associated with continuing an
unstable approach. An awareness of the behavioural traits that result in
continued unstable approaches as well as empowering crewmembers to call
for a go-around will help to reduce decision error during this critical phase.
• Refresh pilot awareness of the requirement to report normalised deviations

and operational workarounds to Jetstar via the appropriate feedback forms.
Engage with front line pilots involved in Queenstown night operations as to
the effectiveness of procedures put in place, address any confusion
surrounding contentious SOP’s and investigate safety issues raised.
• Introduce the concept of Startle Effect, how and why it occurs, how it affects a
pilot’s impulse control and how to recognise it in other crewmembers. As in
SD, emphasise that the startle effect occurs naturally in all humans and can
affect even highly trained pilots. If able, it is encouraged to develop simulator-
training scenarios that evoke a startle response to raise awareness of such
events and to develop skill sets to handle them.
In addition to these HF training recommendations, it was noted that an alarming rate

of threats were present in the pre-departure phase of flight, of which the company
have control over. Procedures should be developed and strictly implemented to reduce
the number of interruptions to the flight deck during this time. Errors made during this
phase of the operations could have catastrophic consequences on the safety of flight.
The following recommendation is presented for consideration in this area:
• Acknowledging the additional complexity of Queenstown operations, allocate

additional time for crewmembers to prepare the aircraft and conduct all
required briefings. Remind cabin crew and ground staff of the dangers of pre-
departure interruptions and distractions, providing guidance around how to
safely and appropriately contact the flight crew.
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Appendix A
Areas Of Vulnerability (AOV) – RNAV ARRIVAL RWY 23 Queenstown

Appendix A
Areas Of Vulnerability (AOV) – RNAV (RNP) Y RWY 23 Queenstown
AOV number and category:

1. HIGH
• ATC imposed requirements: Possible late clearance for approach, frequency changes
from approach to tower frequency interruptions/unreasonable requests from ATC;
• Flight through area that frequently experiences turbulence and strong tailwinds whilst
close to aircraft manoeuvre and/or flap speeds.
• Approach Non Normal Decision Point (NNDP)
2. MEDIUM
• Aircraft intercepts 3.2 degree vertical descent profile
• Company recommended configuration and speed requirements;
• ATC imposed time constraint monitoring at ATVUP
3. HIGH
• Area experiences strong tailwinds causing ‘TOO STEEP PATH’ advice MCDU and
tendency for aircraft to get high on profile;
• Aircraft in FINAL APP will follow vertical approach profile at the expense of managed
and selected speeds. Possible over-speed situation may develop even with speed brake
extended;
• ATC imposed time constraint monitoring at ATVUP
4. MEDIUM
• Area experiences turbulence and high winds through Gibbston Valley
5. HIGH
• LARAV waypoint is the Final Approach Fix (FAF) and Vertical Intercept Point (VIP);
• Radio Altimeter alive at this point;
• Steep terrain rising to the left of approach path leaving narrow terrain corridor;
• Aircraft configured for landing, scan flows and check list requirements;
• ATC weather/runway condition updates, traffic information, clearance to land;
• Strong winds and turbulence exacerbated by local terrain influencing wind direction and
mechanical turbulence;
• Visual illusions due to black-hole phenomena;
• Stabilised approach criteria, possible missed approach/baulked landing procedure.
Appendix B
Classification of AOV, Sampling Rate and Workload Management
Area of
Vulnerability Sampling Rate Required Task/Workload Management
(AOV)
NORMAL SAMPLING RATE PF – Non-flight path related tasks as necessary (updating weather,
Equivalent to the scanning frequency briefing runway changes, etc.); non-essential tasks (eating, casual
required when hand flying an aircraft in conversation, filling out forms, communicating with company, PA
straight and level flight. Implies a rate announcements) along as one pilot is monitoring the flight path.
LOW sufficient to reliably detect change, to
recognise factors that may affect the PM - Non-flight path related tasks as necessary (updating weather,
flight path, and to anticipate the need to briefing runway changes, etc.); non-essential tasks (eating, casual
shift to a higher sampling rate. conversation, filling out forms, communicating with company, PA
announcements) along as one pilot is monitoring the flight path.
ELEVATED SAMPLING RATE
The scanning frequency required of a PF – Flight path management related tasks only
pilot hand flying and aircraft
MEDIUM
approaching imminent change in PM – Non-flight path management related tasks as necessary
trajectory or energy (e.g., approaching a (updating weather, briefing runway changes, etc.)
turn point, or a decent point, or a
configuration change point).
HIGH SAMPLING RATE
HIGH The scanning frequency required of a PF – Flight path management related tasks only
pilot when hand flying an aircraft
through the execution of a significant PM – Flight path management related tasks only
change of trajectory or energy.
Table developed using information obtained from (Flight Safety Foundation, 2014)
Appendix C
The Model of Flight Crew Error Management (Helmreich, Klinect, & Wilhelm, 1999)
External Expected Unexpected External

Threats events/Risks events/Risks Error
Internal Flight Crew

Threats Error
Threat Error detection

CRM recognition and and management
Behaviours error avoidance behaviours
behaviours
Outcomes A safe flight Recovery to a Additional error

safe flight

Incident/Accident
Appendix D
TEM Error Management Model (Helmreich, Klinect, & Wilhelm, 1999)
Appendix E
TEM – Mitigating Strategies (Dean & Pruchnicki, 2015)
When presented with threats, professional pilots want to know how to counter them.
The following mitigation strategies outline proven techniques to overcome normal
human limitations that may erode safety margins:
• Recognize that interruptions can alter human behaviour and seriously erode
safety margins. Interruptions are threats and should be regarded as accident
precursors. Treat any interruption with caution.
• Overcome prospective memory failure by clearly informing your flying
partner if interruptions or operational necessity dictate delaying a checklist.
When doing so, also verbalize a specific plan detailing when the delayed task
will be accomplished. This can enable the other crew member to confirm that
the task will be performed.
• Understand that memory is heavily influenced by cues. A memory aid
recognized by both crew members can serve as a reminder to perform a
delayed task.
• If interrupted while performing a checklist, re-run the entire checklist. Doing
so greatly reduces the probability of succumbing to source memory
confusion.
• To overcome expectation bias, use the say-look-touch confirmation
technique. For example, when confirming proper flap settings while
conducting a checklist, say what the setting should be, look at the flap
position indicator and touch the flap handle. By incorporating multiple
sensory inputs, a higher level of task attentiveness is achieved.
• Slow down. Rushing is a primary initiator of human factors-related failures,
including those associated with repetitive tasks.
• Checklists should be specifically called for by the appropriate pilot in
accordance with SOPs. Doing so ensures that the check-and-balance
philosophy built into them remains intact. It also enhances situational
awareness, as both pilots can remain apprised of the aircraft’s status. Do not
advocate the idea of executing checklists “at your leisure.”
Appendix F
Recommended Elements Of a Stabilized Approach

Night Operations Into Queenstown International Airport: A Human Factors Analysis

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Night Operations Into Queenstown International Airport: A Human Factors Analysis

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Night Operations into

Queenstown International Airport

Prepared for Jetstar Airways Ltd

3. Effective Flight Path Monitoring………………………………… 16

4. Threat and Error Management………………………………….. 21

Jetstar Airways currently operates flights into Queenstown International Airport, a

Threat and Error Management continues to provide a framework that assists in

Pilot incapacitation remains a significant threat to safety, although statistics show a

1.3 Areas of Research

Specific threats identified in section three include ‘incapacitation’ where the

Dr David G. Newman of Flight Medicines Systems Ltd produced a comprehensive

2.1 Visual Illusions

2.1.1 Black hole effect1

Queenstown aerodrome is located on the northern shores of a Lake Wakatipu, the

Boeing engineers Conrad L. Kraft and Charles L. Elworth conducted extensive

Figure 1. Changes in visual angle relative to aircraft position (Schiff, 1990, p. 3)

The result of maintaining a constant visual angle on approach is depicted in figure 2.

2.1.2 Aerodrome Lighting Failure On Approach2

Presently, Jetstar holds an approval (Instrument number: MATFO 183/06) to continue

2.2 Vestibular Illusions

2.2.1 Somatogravic and Somatogyral Illusion3

Somatogravic illusion is where there a strong sensation of pitching up during aircraft

2.3 Contributing Factors

2.3.1 Pilot Factors

2.3.2 Aircraft Factors

“The instrumentation should present a clear and intuitive sense of position,

2.3.3 Operational Factors

as well as instruments. If sufficient visual reference is established during the

Downgrading procedures close to the minima

Downgrading procedures when visual reference to touchdown is not assured

2.3.4 Environmental Factors

2.4 Preventative Measures

Health and Fitness to Fly:

Planning and preparation

Training and education

3. Effective Flight Path Monitoring

• Human Factors limitations;

The recommendations of the WG includes guidance for aviation managers to enact

3.1 Human Factors Limitations

The human brain has difficulty with sustained vigilance

The human brain has quite limited ability to multitask

Humans are vulnerable to interruptions and distractions

3.2 Recommendations to Improve Monitoring Performance

Many of the recommendations are recognised by this report to already be in effect at

3.2.1 Areas of Vulnerability (AOV)

3.2.2 Flight Path Monitoring ‘Sampling Rate’

• A normal sampling rate is equivalent to the scanning frequency required

In Jetstar multi-crew operations the division of workload between flight deck

3.2.3 Task/Workload Management in an AOV10

4. Threat and Error Management

4.1 Introduction to TEM Models

4.2 A Systemic Approach to Mitigating Strategies

4.3 TEM and Jetstar

In addition to Jetstar training programs, Jetstar operations manuals reiterate the

Appendix E includes mitigation strategies that outline proven techniques to

Although research shows the probability of an incapacitation occurring is low, Jetstar

4.5 Unstable Approaches and Runway Excursions13

A stabilised approach is where specific criteria stated in company SOP’s is met

Jetstar policy requires all approaches to be ‘stabilised’, with criteria outlined in

• Excessive confidence in a quick recovery (postponing the go-around decision

• Inadequate management response to evidence of high rates of unstable

It is important to recognise the behavioural traits that influence decision-making at

The following technique is recommended by the FSF as an accident prevention