1 Background

This Briefing Note (BN) takes a look at how a psychological phenomenon called press-on-itis is related to incidents and accidents. Press-on-itis is simply the decision to continue to the planned destination or toward the planned goal even when significantly less risky alternatives exist. Press-on-itis is also known as “get-home-itis,” “hurry syndrome,” “plan continuation” and “goal fixation.” No matter what it is called, press-on-itis can present a serious problem to flight safety. It is important for a pilot to understand the causes of press-on-itis and to recognize when he or she is suffering from the condition. Knowing the causes and recognizing the symptoms will allow a pilot to recover before anything goes terribly wrong.

2 Introduction

Press-on-itis is really the result of a decision-making error that involves continuing toward the destination (objective) despite a lack of readiness of the airplane or crew and the availability of reasonable lower-risk alternatives. Press-on-itis often occurs when there is an unsuitable environment such as bad weather at the destination. The pilot may continue on despite warnings from ATC or other crew members.

Examples of press-on-itis include:

• Conducting multiple approaches despite the weather being unlikely to have improved
• Violating MDA/DH minima
• Flying Visual Flight Rules (VFR) into Instrument Meteorological Conditions (IMC) without being appropriately rated and/or without appropriate equipment
• Racing a thunderstorm to a destination
• Landing in a thunderstorm
• Failure to abide by aircraft performance limits
• Failure to go around from an unstabilized approach
• Failure to plan for a go-around or diversion.

3 Data

The Flight Safety Foundation’s (FSF) Approach-and-landing Accident Reduction (ALAR) Tool Kit study examined 76 approach and landing accidents and serious incidents and showed the most-frequent causal factor (74 percent) was “poor professional judgment/airmanship” (e.g., poor decision making). Press-on-itis accounted for 42 percent of all occurrences in which the crew continued an approach and landing when conditions warranted other action.

Omission of action/inappropriate action (inadvertent deviation from Standard Operating Procedures (SOPs)) was the second most listed causal factor (72 percent. The deliberate non-adherence to procedures was involved in 40 percent of the cases reviewed.

When pilots intentionally deviate from SOPs, it is seldom malicious. In interviews after an accident, they almost always say, “It seemed like the right thing to do based on the information we had at the time.” Assuming that no aircrew deliberately crashes an aircraft, possibly killing themselves and their passengers, why do well-intentioned people make decisions that in hindsight appear grossly inappropriate? The statement, “It would not have happened if they had just followed the rules” is often true, and sometimes the rule that needed to be followed was simply common sense and good airmanship.

4 Discussion of Issues and Concepts

Aircrew must abide by many laws, rules and SOPs. They are required to choose the safest strategies that still allow their airline to operate at reasonable efficiency. These decisions are easier to make when the options are limited to “yes/no” or “go/stop.” However, real-life aviation decisions can get complicated when several options exist, and each decision and action lead to another decision that needs to be made.

In one example of press-on-itis, an aircraft sustained major damage to the tail area, but fortunately no one was killed. The accident occurred when the aircraft struck the ground to the right of the runway when attempting to land from a low-level visual circuit after making two unsuccessful instrument approaches in poor weather. The accident investigation report said, among other things, that there were numerous deviations from SOPs by the flight crew and that such actions precluded the establishment of a stabilized approach and increased the workload of the captain. Following the two unsuccessful attempts at an instrument approach, the captain flew a visual circuit that required aggressive maneuvering. He was still unable to place the aircraft on the runway, and a go-around was called too late by the first officer. As a result, the underside of the aircraft’s tail struck the ground, causing substantial damage to the aircraft.

On the subject of SOP deviation, the accident investigation report stated:

• The captain’s motivation in deviating from SOPs probably derived from professional pride in his ability and concern to provide superior service for the company and its customers.
• The captain understood the relative importance of commercial and safety considerations and had previously diverted aircraft when the situation demanded it.
• The captain did not appear to be exceptionally prone to reckless behavior.
• It seemed likely that the captain relished the challenge of completing this flight as planned under difficult conditions and allowed himself to be deceived into pursuing that challenge in a gradually increasingly risky manner.
• The insidious acceptance of increasing risk in pursuit of a goal is best averted by means of clear planning, considering all the relevant options, and decisive adherence to the plan by all crewmembers.

These comments from the investigation report identify a classic example of press-on-itis in which a pilot deviates from SOPs with the best of intentions, but nevertheless presses on in an increasingly risky manner to achieve a goal.

The report also mentions that there was a disruptive passenger, resulting in the captain having to deal with this issue until approximately 20 minutes prior to the top of descent. After this disruptive event, the captain still allowed a short flight-deck visit by one of the passengers. The condensed pre-descent briefing that was completed by the crew after the flight-deck visit did not include some details of how the crew would conduct the approach.

According to the investigation report, the aims of the pre-descent briefing were not achieved because the first officer was unaware of any proposed deviation from the SOP and that there was no cohesive plan for the approach. Clearly, attempting to achieve the objective of landing the aircraft at the destination without carefully considering the situation and a lack of understanding between the crew can present a significant danger.

While no one was injured in this accident, it could have been much worse. This accident highlights the importance of planning, avoidance of rushing, SOP adherence, briefing and agreeing on planned actions, workload management, good crew resource management (Crew Resource Management) and, above all, not becoming fixated on landing regardless of the ongoing/forthcoming conditions. Much of aviation safety comes from managing risks, and press-on-itis is one of the risks that can be managed through awareness, understanding and institutionalizing defenses and response strategies.

5 Press-on-itis Causal Factors

Aircrews may succumb to press-on-itis for the following reasons:

• They want to “just get the job done” (excessive commitment to task accomplishment) and are influenced by organizational goals such as on-time arrival, fuel savings and passenger convenience
• They may be competitive - “if XXX airline made it, so can we!”
• Personal ego that makes the crew reluctant not to achieve their objective of landing at the original destination
• "We are almost there, let's just do it and get it over with"
• "We do not want to divert, with all the associated additional work"
• They may have diverted once when everyone else landed safely and felt somewhat embarrassed about it or were questioned about their decision
• “Not getting in” may be deemed to be a loss of face
• They are over-confident that nothing will go wrong
• They welcome a chance to demonstrate their skills in challenging situations
• They have a personal commitment/appointment at the completion of the flight, or they may simply want to get to the destination
• They are fatigued
• They become task-saturated
• They focus solely on aircraft flight path control due to turbulence and other distractions
• They miss the significance of ATC calls of changing winds and runway conditions
• They lose situational awareness and are not fully aware of the potentially perilous situation
• They have not set performance limits and trigger gates that require a go-around
• They may have poor CRM skills, and, even if one of the crew members feels uncomfortable about continuing, he or she may therefore not speak up
• They do not conduct a risk assessment based on current and developing (possibly deteriorating) conditions
• They do not anticipate and plan for things that may go wrong
• They are not fully aware of their own limitations and/or the aircraft’s limitations
• They feel nothing matters if they can just get it on the runway and get it stopped.

6 Press-on-itis Prevention Methods

Knowing how press-on-itis can negatively affect aircrew decision making can help lead to recognition of its hazards and, hence, reduced decision errors. The following are ways to prevent press-on-itis:

• The company should commit to safety as a priority and act in such a way that does not contradict that commitment. A company’s safety culture is defined by how it rewards its employees whether it be with words of praise, a pat on the back, a promotion or a pay increase for their effort to improve safety standards. Even if there is a “Safety is Job Number 1” sign on the wall, excessive pressure for potentially risky actions such as on-time arrivals, fuel savings and passenger convenience can result in press-on-itis.
• The company should have a sound training program about the dangers of press-on-itis and other matters relating to safety and human factors. The company should also emphasize the importance of observing the minima and procedures.
• Crews should be indoctrinated in the error-reducing benefits of proper planning. A crew should use “what if?” scenarios that are related to the mission. Preplanning among captain, first officer and dispatcher allows everyone a chance to comment and gain a shared mental model of possible alternate plans.
• Crews should be taught to ask “why?” when they select the more risky of two alternatives.
• Company policy and crew training should emphasize carrying enough fuel for diversion and/or holding.
• Crews should be trained concerning how to select a suitable alternate. This should include not choosing a “close-in alternate” that will be affected by the same weather system.
• Crews should be trained in how to carry out a risk assessment based on crew fatigue level and type of approach (precision, non-precision, etc.). For example, a circling approach at night entails much more risk than flying a precision approach.
• SOPs and training should stress the selection of a runway with vertical guidance even if it is not the noise abatement runway.
• Crews should be trained and required to calculate the increased stopping distance required for a contaminated runway based on the estimated ground speed, Minimum Equipment List (MEL) limits, etc.
• Training should emphasize the need to:
  • Review and brief the crosswind/tailwind limits for weather and runway conditions.
  • Brief the planned approach including aircraft configuration, navigation and automation procedures.
  • Clearly brief performance limits and minima for approach Review and brief the crosswind/tailwind limits for weather and runway.
  • Be go-around minded. If everything is not within limits, go around.
  • Take the necessary time to re-brief and set up for a new approach if plans change. Do not rush, and do not let ATC pressure you into a rushed approach.
  • Fly the aircraft onto the runway at the proper touchdown point. If the approach does not look right or feel right, then go around.
  • Be mindful of the danger of letting one's own commitments or circumstances or the commitments of the rest of the crew influence your decisions.
  • Conduct a debrief after every flight. Recognize that just because you made it in safely this time does not mean it was a wise decision. Learn from those experiences, recognize the precursors of an accident and divert or go around early.

7 Key Points

• Press-on-it is a dangerous mental state that can affect even the best and most experienced pilots.
• Many accidents are caused, or suspected to be caused or contributed to by press-on-itis.
• Unreasonable pressure to get to the destination, whether self-generated or externally-imposed, can cause an aircrew to decide to continue to their planned destination despite conditions being unsuitable to do so.
• Company policies must truly place safety first and reward safe decision making.
• Good training that stresses awareness of the dangers of press-on-itis, setting boundaries, sound knowledge of rules and procedures, disciplined adherence to minima and performance requirements, and planning to deal with potential situations will act as defenses against unsafe conditions.

8 Associated OGHFA Material

Briefing Notes:

• Decision Making
• Crew Resource Management
• Company Safety Culture

Situational Examples:

• ETOPS Diversion at Night
• Landing At Wrong Airport
• Non-stabilized Approach After ATC-Requested Runway Change
• Press-on-itis and Inadequate Use of Automation
• Runway Overrun After Unstabilised Approach

9 Additional Reading Material/ Websites References

• Flight Safety Foundation Approach and Landing Accident Reduction (ALAR) Toolkit

• Flight Safety Foundation Managing Threats and Errors during Approach and Landing

• Flight Safety Foundation Accident Prevention, Vol. 56 No. 5, May 1999 “B-757 Damaged by Ground Strike During Late Go-around from Visual Approach” http://www.flightsafety.org/ap/ap_may99.pdf

• Accident investigation reports produced by various investigation bodies around the world (the US NTSB, the UK AAIB, TSB Canada, Australian ATSB, etc.) are also good resources for learning more about the dangers of press-on-itis.

Related SKYbrary Articles

• Crew Resource Management (CRM)
• Safety Culture